CurrentBlue Cross Blue Shield - IowaPolicy 05.04.54

Firdapse (amifampridine) for Lambert-Eaton myasthenic syndrome (LEMS)

Defines coverage, prior authorization documentation requirements, initial and continuation approval criteria, exclusions, and quantity limits for Firdapse (amifampridine) for treatment of Lambert-Eaton myasthenic syndrome in adults and pediatric patients ≥6 years.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyFirdapse (amifampridine) for Lambert-Eaton myasthenic syndrome (LEMS)

Policy CodePolicy 05.04.54

Change TypeReviewed (no material change)

Effective DateApr 1, 2022

Next Review Date

Key ActionPrior authorization is required and submission must include either EMG report or anti-P/Q VGCC antibody test to initiate review.

POLICY UPDATE CHANGES

Reviewed June 2025 (policy reviewed).

1Covered Indication (LEMS)

240/tabQuantity Limit

6Initial Authorization (months)

12Continuation Authorization (months)

Coverage Summary

Coverage stance: covered_with_criteria. Scope: Defines coverage, prior authorization documentation requirements, initial and continuation approval criteria, exclusions, and quantity limits for Firdapse (amifampridine) for treatment of Lambert-Eaton myasthenic syndrome in adults and pediatric patients ≥6 years. Subject: Firdapse (amifampridine) for Lambert-Eaton myasthenic syndrome (LEMS). Age indication: patients ≥6 years. Effective date: 2022-04-01. Last review: 2025-06-01.