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Limited coverage criteria – amifampridine

Last updated on March 24, 2025

 

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Generic name

 amifampridine

Strength & form

 10 mg 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, when requested by a neurologist with expertise in managing LEMS

3 months

Renewal

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

  • 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 (coverage is limited to a maximum of 80 mg daily)

Special Authority request form(s)