Self administration- Oral
Indications for Prior Authorization
- indicated to improve walking in patients with multiple sclerosis (MS).
Patients must meet the following criteria for the indications above.
- Diagnosis of MS confirmed by a neurologist
- Creatinine clearance > 50 ml/min Ampyra is contraindicated in moderate - severe renal impairment.
- An EDSS score of <seven (patient must be ambulatory) Ampyra is contraindicated in patients with a history of seizure.
Seizures in patients taking Ampyra should be reported to Acorda drug safety at 1-800-367-5109 or the FDA (1-800-332-1088).
All coverage requests must include the results of two walking studies as baseline data.
The Following Conditions Do Not Meet the Criteria for Use as Established by the WHA P & T Committee.
- All non-FDA approved indications
Ampyra 10 mg PO every 12 hours
Use of doses higher than 10 mg twice a day may increase the risk of seizure.
Ampyra therapy will be approved initially for a three month trial.
Renewal requires chart note documentation of improvement in the patient's walking parameters such as distance and speed.
Western Health Advantage Pharmacy and Therapeutics Committee
Approved/Revised: November 2010 Reviewed: July 2011 Reviewed: Dr. John Schafer