Firdapse — Medical Mutual

Initial criteria

• Patient is age ≥ 18 years if requesting Firdapse OR age ≥ 6 years if requesting Ruzurgi
• Patient has confirmed LEMS based on at least one electrodiagnostic study (e.g., repetitive nerve stimulation) OR anti-P/Q-type voltage-gated calcium channels antibody testing, according to the prescribing physician
• Patient has moderate to severe weakness that interferes with daily functions
• Patient does not have a history of seizures
• Requested agent is being prescribed by or in consultation with a neurologist or neuromuscular specialist

Reauthorization criteria

• Patient has had a clinical response to therapy, as determined by the prescriber

Approval duration

initial: 3 months; reauth: 1 year