Ampyra — Cigna
Multiple sclerosis (to improve walking)
Preferred products
- generic dalfampridine
Initial criteria
- Patient meets the standard Multiple Sclerosis – Dalfampridine Prior Authorization Policy criteria; AND
- Patient has tried generic dalfampridine [documentation required]; AND
- Patient cannot continue to use generic dalfampridine due to a formulation difference in the inactive ingredient(s) [e.g., difference in dyes, fillers, preservatives] between the Brand and the bioequivalent generic which, per the prescriber, would result in a significant allergy or serious adverse reaction [documentation required].
Reauthorization criteria
- Patient continues to meet the initial criteria.
Approval duration
1 year