amifampridine phosphate — Blue Cross Blue Shield of Oklahoma

Initial criteria

• Patient has a diagnosis of Lambert Eaton myasthenic syndrome 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: (A) 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 prescriber has consulted with a specialist in the area of the patient’s diagnosis
• Patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

• 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 the area of the patient’s diagnosis
• Patient does NOT have any FDA labeled contraindications to the requested agent

Approval duration

6–12 months (plan dependent)