CurrentCignaPolicy N/A

Ampyra (dalfampridine) prior authorization

This document is a Cigna prior-authorization form and attestation for prescribing Ampyra (dalfampridine) for patients (primarily with multiple sclerosis) requesting coverage of the medication; it governs what information providers must submit for review.

Policy Summary

PayerCigna

PolicyAmpyra (dalfampridine) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior-authorization form with patient/prescriber details, medication information, indication, and clinical documentation of benefit for continuation requests.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time for prescription drug coverage requests

800.882.4462phone number for urgent requests

(855) 840-1678fax number to send completed form

Accredopreferred specialty pharmacy

Coverage criteria and form-based authorization

Policy Summary

PayerCigna

PolicyAmpyra (dalfampridine) prior authorization

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit the completed prior-authorization form with patient/prescriber details, medication information, indication, and clinical documentation of benefit for continuation requests.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Submission requirements: Provider submits complete patient/prescriber details and medication information including medication name, directions for use, dose, quantity, duration of therapy, and whether this is a new start or continuation.

Form fields capture these elements.

Clinical indication and prescriber qualifications: Documentation indicates whether Ampyra will be used to improve mobility in an individual with multiple sclerosis (MS) and whether the medication is prescribed by or in consultation with a neurologist or MS specialist.

Checked boxes on the form for indication and prescriber specialty.

Continuation therapy: For continued therapy, documentation of a beneficial clinical response (for example, improved strength, coordination, or balance) is required.

Form asks for indication of benefit for continued therapy (Yes/No) and supporting documentation is expected.

Additional clinical details: Provide additional pertinent information including disease stage, prior therapy, performance status, and names/doses/administration schedule of concurrent agents.

Free-text field on form for supporting clinical details.

What providers must do to request coverage

Prior Authorization

Prior Authorization Required

Prior authorization is required. Submit a completed Cigna prior authorization form (fax or online) — save time by submitting online at www.covermymeds.com or via SureScripts in your EHR. Fax completed form to: (855) 840-1678. Our standard response time for prescription drug coverage requests is 5 business days; if urgent, call (800) 882-4462 (800.88.CIGNA) to expedite the request.

Fax: (855) 840-1678
Online: www.covermymeds.com/main/prior-authorization-forms/cigna/
Urgent phone: (800) 882-4462
Standard review timeframe: 5 business days

Documentation Required

Required Submission Elements

Required submission elements: complete all patient and prescriber fields (asterisked items are mandatory), including physician name, specialty, DEA/NPI/TIN, office contact, patient name, Cigna ID, date of birth, addresses, and phone/fax. Provide medication details (name, ICD-10, directions, dose, quantity, duration), indication (new start vs continuation), and supporting clinical information as listed on the form.

Complete all asterisked (*) patient and prescriber fields on the form
Medication requested: name, ICD-10, directions, dose, quantity, duration
Indicate new start or continuation of therapy
Include prescriber signature and date

Documentation Required

Continuation Therapy Documentation

Continuation therapy requests must include documentation of beneficial clinical response. For continuation, indicate whether the patient has experienced improvement (examples: improved strength, coordination, or balance) and provide relevant clinical notes, disease stage, prior therapies, performance status, and names/doses/schedules of concurrent agents.

Document clinical benefit for continued therapy (e.g., improved strength, coordination, balance)
Provide additional pertinent information: disease stage, prior therapy, performance status, concurrent medications

Note

Preferred Pharmacy

Preferred specialty pharmacy: Accredo is Cigna's nationally preferred specialty pharmacy. The form asks where the medication will be obtained; indicate Accredo when applicable. Medication orders can be placed with Accredo via e-prescribe, fax (888.302.1028), or verbal (866.759.1557).

Preferred specialty pharmacy: Accredo
Accredo contact: Fax 888.302.1028; Verbal 866.759.1557; NCPDP 4436920

Denial Risk

Incomplete Clinical Documentation Risks

Incomplete clinical documentation may delay or lead to denial. Ensure the form includes the clinical reason for use, prescriber specialty or consultation (neurologist or MS specialist when applicable), and evidence of benefit for continuation requests.

Document use (e.g., improve mobility in MS) and prescriber specialty/consultation
Failure to provide key clinical details and evidence of benefit may risk denial or delay

OpenPayer

Ampyra (dalfampridine) prior authorization

Coverage criteria and form-based authorization

Medication, diagnosis, and pharmacy identifiers

What providers must do to request coverage

Clinical background

Key definitions