amifampridine phosphate — Blue Cross Blue Shield of Kansas

Initial criteria

• The patient has a diagnosis of Lambert Eaton myasthenic syndrome (LEMS) confirmed by at least ONE of the following: (medical records required)
• A. Neurophysiology study (e.g., nerve conduction studies [CMAP], EMG, repetitive stimulation) OR
• B. Anti-P/Q-type voltage-gated calcium channels (VGCC) antibody testing
• 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
• 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 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