Subject: Specialty Quantity Limit Firdapse 2828-H P2023a

Drug

FIRDAPSE  (amifampridine)

Policy:

I.  PROGRAM DESCRIPTION

The standard limit is designed to allow a quantity sufficient for the most common uses of the medication. The recommended dosing parameters for Lambert-Eaton myasthenic syndrome (LEMS) fall within the standard limits. Coverage of an additional quantity may be reviewed on a case-by-case basis upon request.


II.  COVERED QUANTITIES

Medication	Standard Limit	FDA-recommended dosing
Firdapse (amifampridine) 10 mg tablets	300 per 30 days	Adult and pediatric members weighing 45 kg or more: Recommended starting  dose is 15 mg to 30 mg daily in divided doses (3 to 5 times daily). The dosage can  be increased by 5 mg daily every 3 to 4 days. The maximum single dose is 20 mg.  The maximum daily maintenance dosage is 100 mg.  Pediatric members weighing less than 45 kg: Recommended starting dose is  5 mg to 15 mg daily in divided doses (3 to 5 times daily). The dosage can be  increased by 2.5 mg daily every 3 to 4 days. The maximum single dose is 10 mg.  The maximum daily maintenance dosage is 50 mg.

 

 

Place of Service:

Outpatient

The above policy is based on the following references:

1. Firdapse [package insert]. Coral Gables, FL: Catalyst Pharmaceuticals, Inc.; May 2024.

 

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

July 20, 2024