CurrentCareSourcePolicy N/A

PHARMACY POLICY STATEMENT Arkansas PASSE

Defines pharmacy benefit coverage, prior authorization, quantity limits, clinical criteria for initial and reauthorization use of Firdapse (amifampridine) for Lambert-Eaton myasthenic syndrome (LEMS) under the Arkansas PASSE program. Also states not medically necessary indication(s).

Policy Summary

PayerCareSource

PolicyPHARMACY POLICY STATEMENT Arkansas PASSE

Policy CodePolicy N/A

Change TypePolicy creation; administrative revision

Effective DateJan 1, 2022

Next Review Date

Key ActionObtain prior authorization and provide diagnostic test results (RNS demonstrating ≥60% post-exercise CMAP increase or positive anti-P/Q VGCC antibody) plus a baseline ECG within 12 months showing QT < 450 ms.

SourceLink

POLICY UPDATE CHANGES

New policy for Firdapse created.

Removed prescriber specialty requirement and baseline Quantitative Myasthenia Gravis (QMG) testing requirement.

1Covered Indications (LEMS)

1Not Covered Indications (MG)

240Quantity limit (30 days)

Coverage Summary

Firdapse (amifampridine) is covered with criteria under the pharmacy benefit for adult members with Lambert-Eaton myasthenic syndrome (LEMS). Coverage requires prior authorization and diagnostic confirmation; the policy specifies a quantity limit of 240 tablets per 30 days and allows site of service in the home. The policy also states that treatment of myasthenia gravis (MG) is not medically necessary.