Firdapse — Blue Cross Blue Shield of Illinois

Lambert Eaton myasthenic syndrome (LEMS)

Initial criteria

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 (medical records required)
If the patient has an FDA labeled indication, then ONE of the following: (A) The patient's age is within FDA labeling for the requested indication for the requested agent OR (B) There is support for using the requested agent for the patient's age for the requested indication
Prescriber is a specialist in the area of the patient's diagnosis (e.g., neurologist, oncologist) or has consulted with a specialist in that area
Patient does NOT have any FDA labeled contraindications to the requested agent
Alternative approval for members residing in Ohio AND plan is Fully Insured or HIM Shop (SG) AND: (A) No FDA labeled contraindications AND (B) ONE of the following: (1) Patient has another FDA labeled indication for the requested agent and route of administration OR (2) Patient has another indication supported in compendia for the requested agent and route of administration OR (3) Prescriber has submitted TWO articles from major peer-reviewed journals (e.g., JAMA, NEJM, Lancet) supporting the proposed use(s) as generally safe and effective

Patient has been previously approved for the requested agent through the plan’s Prior Authorization process
Patient has had clinical benefit with the requested agent
Prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist, oncologist) or has consulted with a specialist in that area
Patient does NOT have any FDA labeled contraindications to the requested agent

BCBSIL/BCBSMT/BCBSTX: 12 months; Other plans: 6 months initial, 12 months renewal