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Ampyra — Blue Cross Blue Shield of Alabama

multiple sclerosis (MS)

Initial criteria

  • ONE of the following:
  • • The patient has a diagnosis of multiple sclerosis (MS) AND ALL of the following:
  •  • ONE of the following:
  •   • The patient will be using a disease modifying agent for the treatment of MS (e.g., Aubagio, Avonex, Bafiertam, Betaseron, Briumvi, Copaxone, Extavia, Gilenya, Glatopa, Kesimpta, Lemtrada, Mavenclad, Mayzent, Ocrevus, Plegridy, Ponvory, Rebif, Rituxan, Tascenso ODT, Tecfidera, Tysabri, Vumerity, Zeposia) in combination with the requested agent
  •   OR
  •   • The patient has an intolerance, hypersensitivity, or FDA labeled contraindication to ALL disease modifying agent drug classes used for the treatment of MS
  •  AND Information has been provided that the patient has significant limitations attributable to slow ambulation
  •  AND The patient is ambulatory with a baseline (prior to therapy with the requested agent) timed 25-foot walk of 8 to 45 seconds
  •  AND Information has been provided that the patient has a current EDSS score less than 7
  • • OR The patient has another FDA approved indication for the requested agent and route of administration
  • AND ONE of the following:
  •  • The patient’s age is within FDA labeling for the requested indication for the requested agent
  •  OR The prescriber has provided information in support of using the requested agent for the patient’s age
  • AND The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist) or has consulted with a specialist
  • AND The patient does NOT have any FDA labeled contraindications to the requested agent
  • AND If the requested agent is one of the following brand agents with available generic equivalents, then ONE of the following must apply:
  •  Brand: Ampyra; Generic Equivalent: dalfampridine
  •  • The patient has an intolerance or hypersensitivity to the generic equivalent that is not expected to occur with the brand agent
  •  OR The patient has an FDA labeled contraindication to the generic equivalent that is not expected to occur with the brand agent
  •  OR The prescriber has provided information to support the use of the requested brand agent over the generic equivalent

Reauthorization criteria

  • The patient has been previously approved for the requested agent through the plan’s Prior Authorization Review process
  • AND ONE of the following:
  • • The patient has a diagnosis of multiple sclerosis (MS) AND ALL of the following:
  •  • Information has been provided that the patient has had stabilization or improvement from baseline (before treatment with requested agent) in timed walking speed or EDSS score with the requested agent
  •  AND The patient is ambulatory
  •  AND Information has been provided that the patient has a current EDSS score of less than 7
  •  AND ONE of the following:
  •   • BOTH of the following:
  •    • The patient is currently treated with a disease modifying agent for the treatment of MS (e.g., Aubagio, Avonex, Bafiertam, Betaseron, Briumvi, Copaxone, Extavia, Gilenya, Glatopa, Kesimpta, Lemtrada, Mavenclad, Mayzent, Ocrevus, Plegridy, Ponvory, Rebif, Rituxan, Tascenso ODT, Tecfidera, Tysabri, Vumerity, Zeposia)
  •    AND The patient will continue a disease modifying agent for the treatment of MS in combination with the requested agent
  •   OR The patient has an intolerance, hypersensitivity, or FDA labeled contraindication to ALL disease modifying agent drug classes used for the treatment of MS
  • • OR The patient has another FDA approved indication for the requested agent AND has had stabilization or clinical improvement with the requested agent

Approval duration

6 months for MS; 12 months for another FDA approved diagnosis