Limited coverage criteria – amifampridine phosphate

Last updated on March 24, 2025

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Generic name	amifampridine phosphate
Strength & form	10 mg of amifampridine base tablet

Special Authority criteria	Approval period
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 Requested by a neurologist with expertise in managing LEMS	1 year

Special Authority criteria

Approval period

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

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)

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HLTH 5828 - Amifampridine (PDF, 100KB)

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