Limited coverage drugs – amifampridine

Generic name

 amifampridine

Strength

 10 mg

Form

 tablet

Special Authority criteria

Approval period

Initial:

For the symptomatic treatment of patients with Lambert-Eaton myasthenic syndrome (LEMS) who are 6 years of age and older

AND

Requested by a neurologist with expertise in managing LEMS

3 months

Renewal:

The patient has attained and maintained a minimum reduction of 30% on the Triple Timed Up-and-Go (3TUG) test result when compared to the pre-amifampridine 3TUG test result.

AND

Requested by a neurologist with expertise in managing LEMS		 1 year

Practitioner exemptions

  • None

Special notes

  • The maximum dose of amifampridine should not exceed 80 mg daily.

Special Authority request form(s)