dalfampridine — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years
• Patient is ambulatory
• Dalfampridine is being used to improve or maintain mobility
• Patient has impaired ambulation as evaluated by an objective measure
• Medication is being 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
• Patient is ambulatory
• Dalfampridine is being used to improve or maintain mobility
• Patient has impaired ambulation as evaluated by an objective measure
• Dalfampridine is being prescribed by, or in consultation with, a neurologist or a physician who specializes in the treatment of multiple sclerosis
• According to the prescriber the patient has experienced an improvement or maintenance in walking speed or other objective measures related to ambulation

Approval duration

initial: 4 months; reauth: 1 year