Firdapse — Blue Cross Blue Shield of Alabama

Initial criteria

• The patient has a diagnosis of Lambert-Eaton myasthenic syndrome (LEMS) confirmed by at least ONE of the following: neurophysiology study (e.g., nerve conduction studies [CMAP], EMG, repetitive stimulation) OR anti-P/Q-type voltage-gated calcium channels (VGCC) antibody testing
• If the patient has an FDA-labeled indication, then ONE of the following: the patient’s age is within FDA labeling for the requested indication for the requested agent OR there is support for using the requested agent for the patient’s age for the requested indication
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, oncologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
• The patient does NOT have any FDA-labeled contraindications to the requested agent

Reauthorization criteria

• The patient has been previously approved for the requested agent through the plan’s Prior Authorization process
• The patient has had clinical benefit with the requested agent
• The patient has not developed a history of seizures while using the requested medication
• The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, oncologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
• The patient does NOT have any FDA-labeled contraindications to the requested agent

Approval duration

initial 6 months; renewal 12 months