Ampyra (dalfampridine extended-release tablets - Acorda, generic) — Cigna

Initial criteria

• Patient is age ≥ 18 years; AND
• Patient is ambulatory; AND
• Dalfampridine is being used to improve or maintain mobility; AND
• Patient has impaired ambulation as evaluated by an objective measure (e.g., Timed 25-Foot Walk, Multiple Sclerosis Walking Scale-12); AND
• Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis.

Reauthorization criteria

• Patient is age ≥ 18 years; AND
• Patient is ambulatory; AND
• Dalfampridine is being used to improve or maintain mobility; AND
• Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis; AND
• According to the prescriber, the patient has experienced an improvement or maintenance in walking speed or other objective measures related to ambulation (e.g., Timed 25-Foot Walk, Multiple Sclerosis Walking Scale-12).

Approval duration

initial: 4 months; renewal: 1 year