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    v1.0.28
    OpenPayerPolicy UpdatesPharmacy & Specialty DrugsCareSource GA Dalfampridine Prior Auth | OpenPayer
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    CurrentCareSource GeorgiaPolicy GA-MED-P-366579

    Dalfampridine Coverage for Multiple Sclerosis Walking Impairment

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    This policy governs pharmacy prior authorization coverage of dalfampridine, the generic for Ampyra, for CareSource Georgia Medicaid members. It applies to adults with multiple sclerosis who have impaired walking ability and establishes initial authorization, quantity, contraindication, and reauthorization requirements.

    Policy Summary
    PayerCareSource Georgia Medicaid
    PolicyDalfampridine Coverage for Multiple Sclerosis Walking Impairment
    Policy CodePolicy GA-MED-P-366579
    Change TypeMaterial clinical and coverage update
    Effective DateMarch 1, 2026
    Next Review DateNot specified
    Key ActionSubmit pharmacy prior authorization with documentation that all initial clinical and safety criteria are met.
    SourceLink
    POLICY UPDATE CHANGES

    The policy was transferred to a new template and references were updated.

    The policy added multiple sclerosis diagnosis and impaired walking ability requirements.

    Contraindication requirements were added for seizure history and moderate or severe renal impairment.

    The requirement for concomitant treatment with another medication was removed.

    The initial approval duration was shortened from 6 months to 3 months.

    The policy was modified from Ampyra to dalfampridine, the generic equivalent.

    18+Minimum member age for initial authorization

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    8-45 sec
    Required baseline timed 25-foot walk range
    60 tabletsQuantity limit per 30 days
    3 monthsInitial authorization duration
    12 monthsAdditional authorization duration after reauthorization
    CrCl ≤50Renal impairment threshold that precludes initial coverage

    Coverage Criteria

    Initial Therapy

    For initial authorization, coverage is provided when ALL of the following criteria are met:

    ALL of the following

    • Member is at least 18 years of age.
    • Medication is prescribed by or in consultation with a neurologist.
    • Member has a diagnosis of multiple sclerosis (MS), any type.
    • Member is ambulatory, with or without an assistive device, and has impaired walking ability.
    • Member has a baseline timed 25-foot walk (T25FW) between 8 and 45 seconds.8–45 seconds
    • Member does not have a history of seizures.
    • Member does not have moderate or severe renal impairment (creatinine clearance [CrCl] 50 mL/min or less).CrCl > 50 mL/min
    • Dosage does not exceed 10 mg every 12 hours.

      Quantity limit: 60 tablets per 30 days.

    Continuation Therapy

    For reauthorization, coverage is provided when the following criterion is met:

    Required criterion

    • Chart notes document increased walking speed compared with baseline, such as an improved timed 25-foot walk (T25FW).

    CareSource considers dalfampridine not medically necessary for the treatment of conditions or indications that are not listed in this document.

    Treatment of any unlisted condition is considered not medically necessary; for other indications, refer to the Off-Label policy.

    Clinical Thresholds

    Baseline timed 25-foot walk
    MeasureBaseline timed 25-foot walk (T25FW)
    Required rangeBetween 8 and 45 seconds
    Authorization impactA baseline T25FW outside the 8-to-45-second range does not meet the initial authorization criterion
    Renal function
    Required renal functionCreatinine clearance greater than 50 mL/min
    Exclusion thresholdCreatinine clearance of 50 mL/min or less
    Coverage requirementMember must not have moderate or severe renal impairment

    Authorization and Documentation Actions

    Prior Authorization

    Initial Prior Authorization Required

    Pharmacy prior authorization is required for dalfampridine. Submit the initial clinical documentation demonstrating that the member meets the policy criteria; when approved, initial authorization is limited to 3 months.

    • Dalfampridine 10 mg every 12 hours; quantity limit: 60 tablets per 30 days.
    Documentation Required

    Reauthorization

    For reauthorization, submit the required chart-note documentation. If the renewal requirements are met, dalfampridine will be authorized for an additional 12 months.

    • Renewal authorization duration: 12 months.
    Documentation Required

    Clinical Background

    Dalfampridine is a potassium channel blocker indicated to improve walking in adults with multiple sclerosis. Clinical benefit was demonstrated by increased walking speed. Dalfampridine is a symptomatic treatment and does not alter overall disease progression; it is typically used as an add-on to disease-modifying treatment.

    Initial Dalfampridine Authorization

    Initial Dalfampridine Authorization

    Initial dalfampridine authorization requires ALL of the following nested criteria to be satisfied:

    Initial dalfampridine authorization

    • Clinical eligibility

      • Member is at least 18 years of age.Age ≥18
      • Medication is prescribed by or in consultation with a neurologist.
      • Member has a diagnosis of multiple sclerosis of any type.
      • Member is ambulatory, with or without an assistive device, and has impaired walking ability.

    Dalfampridine Reauthorization

    Dalfampridine Reauthorization

    Reauthorization is available when the following requirement is met:

    Continuation therapy: Chart notes must document increased walking speed compared with baseline, such as an improved timed 25-foot walk.Improved walking speed from baseline

    Approval duration is an additional 12 months when the requirement is met.

    Quantity and Dosing Limits

    Dalfampridine quantity limit
    DrugDalfampridine
    Quantity limit60 tablets
    Limit periodPer 30 days
    Dalfampridine dosing
    DrugDalfampridine
    Dose10 mg
    FrequencyEvery 12 hours
    Policy Summary
    PayerCareSource Georgia Medicaid
    PolicyDalfampridine Coverage for Multiple Sclerosis Walking Impairment
    Policy CodePolicy GA-MED-P-366579
    Change TypeMaterial clinical and coverage update
    Effective DateMarch 1, 2026
    Next Review DateNot specified
    Key ActionSubmit pharmacy prior authorization with documentation that all initial clinical and safety criteria are met.
    SourceLink
    On This Page
    Coverage CriteriaClinical ThresholdsAuthorization and Documentation ActionsClinical BackgroundInitial Dalfampridine AuthorizationDalfampridine ReauthorizationQuantity and Dosing Limits

    Document Response for Renewal

    Chart notes must document an increased walking speed compared with baseline, such as an improved timed 25-foot walk (T25FW), to support renewal.

    • Include the member’s follow-up T25FW or other chart-note evidence showing improvement from baseline.
    Denial Risk

    Initial Eligibility and Contraindication Requirements

    Initial authorization may be denied when any required eligibility or safety condition is not met.

    • Member must be at least 18 years old.
    • Medication must be prescribed by or in consultation with a neurologist.
    • Member must have multiple sclerosis of any type.
    • Member must be ambulatory, with or without an assistive device, and have impaired walking ability.
    • Baseline T25FW must be between 8 and 45 seconds.
    • Member must not have a history of seizures.
    • Member must not have moderate or severe renal impairment (creatinine clearance 50 mL/min or less).
    Denial Risk

    Insufficient Response Documentation

    Reauthorization may be denied when the submitted chart notes do not document increased walking speed compared with the member’s baseline.

    • An improved T25FW is an example of acceptable response documentation.
    Denial Risk

    Unlisted Indication Not Covered

    Dalfampridine is not medically necessary for conditions or indications not listed in this policy. For other indications, refer to the applicable Off-Label policy.

  1. Member has a baseline timed 25-foot walk between 8 and 45 seconds.T25FW 8–45 seconds

  2. Safety requirements

    • Member does not have a history of seizures.
    • Member does not have moderate or severe renal impairment.Creatinine clearance >50 mL/min required

      Creatinine clearance of 50 mL/min or less is excluded.

  3. Dose and quantity requirements

    • Dose is 10 mg every 12 hours.10 mg every 12 hours
    • Quantity does not exceed 60 tablets per 30 days.60 tablets per 30 days