Prior Authorization Criteria for Approval
Initial Evaluation
Dalfampridine will be approved when ALL of the following are met:
- The patient has a diagnosis of multiple sclerosis (MS)
AND - ONE of the following:
- If indicated, the requested medication will be used in combination with a disease modifying agent [e.g., dimethyl fumarate, glatiramer (e.g., Copaxone)]
OR - The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to a disease modifying medication
OR - The prescriber has provided information indicating that a disease modifying medication is not clinically appropriate for the patient
AND
- If indicated, the requested medication will be used in combination with a disease modifying agent [e.g., dimethyl fumarate, glatiramer (e.g., Copaxone)]
- The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
AND - The patient does NOT have any FDA labeled contraindications to the requested medication
Length of Approval: 3 months
Renewal Evaluation
Dalfampridine will be approved when ALL of the following are met:
- The patient has been previously approved for the requested medication through the plan’s Prior Authorization criteria
AND - The patient has a diagnosis of multiple sclerosis (MS)
AND - ONE of the following:
- If indicated, the requested medication will be used in combination with a disease modifying agent [e.g., dimethyl fumarate, glatiramer (e.g., Copaxone)]
OR - The patient has an intolerance, FDA labeled contraindication, or hypersensitivity to a disease modifying medication
OR - The prescriber has provided information indicating that a disease modifying medication is not clinically appropriate for the patient
AND
- If indicated, the requested medication will be used in combination with a disease modifying agent [e.g., dimethyl fumarate, glatiramer (e.g., Copaxone)]
- The prescriber is a specialist in the area of the patient’s diagnosis (e.g., neurologist) or the prescriber has consulted with a specialist in the area of the patient’s diagnosis
AND - The patient has had improvements or stabilization from baseline in timed walking speed (timed 25-foot walk)
AND - The patient does NOT have any FDA labeled contraindications to the requested medication
Length of Approval: 12 months
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