Limited coverage drugs – amifampridine phosphate

Initial:

For the symptomatic treatment of patients with Lambert-Eaton myasthenic syndrome (LEMS) who are 18 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 phosphate 3TUG test result

AND