Patient information prescriber information complete the. If youve made up your mind to ask your health care professional about gilenya, heres a great way to check another todo item off your list. Ampyra prior authorization form if this is an urgent request, please call upmc health plan pharmacy services. This information does not take the place of talking with your doctor about your medical condition or your treatment.
I am 52 and did read people over 50 have to be careful with taking it so i need to ask about that as well. History of hypersensitivity to ampyra or 4aminopyridine 4. Each tablet contains 10 mg dalfampridine, formulated as an extended. Patient must have a confirmed diagnosis of multiple sclerosis any form. Please complete all pages to avoid a delay in our decision. All fda approved indications not otherwise excluded from part d.
When initiating and continuing treatment with tysabri, physicians should consider whether the expected benefit of. Instructions for patients please write legibly and complete all required fields on the ocrevus start form to prevent delays. Dalfampridine ampyra is supplied as 10mg filmcoated, extendedrelease, white to offwhite, oval tablets. However, please note that we cannot assist you without your signed authorization.
Please complete all fields to avoid any delays in processing. Please type or print neatly please complete all sections of. Copy both sides of the patients medical insurance card and pharmacy benefit card, if available. Aug 08, 2018 ampyra dalfampridine is a potassium channel blocker. Ampyra dalfampridine extendedrelease tablets side effects. Jan 22, 2010 ampyra dalfampridine extended release tablets company. Ampyra patient support services center free 60 day trial. It is not known whether this medicine will harm an unborn baby. Jan, 2020 if you also take a form of this medicine obtained from a compounding pharmacy fampridine, or 4aminopyridine. I authorize ampyra patient support services to contact patient directly to obtain patient signature. Webmd explains how ampyra works, including its side effects. When initiating and continuing treatment with tysabri, physicians should.
Ampyra dalfampridine prior authorization with quantity. Dispense as written brand exchange permissible date. Dalfampridine ampyra is an oral medication, in tablet form, which blocks tiny pores, or potassium channels, on the surface of nerve fibers. Your doctor may do a blood test to check how well your kidneys are working before you start ampyra. Page 2 of 2 section b physician signature physician signature date fax completed form to. Ampyra express scripts prior authorization phone 18444248886 fax 18772515896. Difficulty with walking is one of the most reported challenges of having ms. Ampyra is a drug used to improve the walking ability of people with multiple sclerosis ms. You may be able to lower your total cost by filling a greater quantity at one time. Patient authorization and betaplus enrollment form for. Ampyra fchp 920 cvs caremark specialty pharmacy 2211 sanders road nbt6 northbrook, il 60062 phone. This facsimile transmission is intended to be delivered only to the name addressee and may contain material that is confidential, privileged, proprietary or. This will enable you to enroll in biogen support services, which can provide help with financial services, navigating insurance, or learning more about your therapy see for eligibility guidelines.
Side effects seen in clinical trials include urinary tract infection, insomnia, dizziness, headache, nausea, back pain, loss of muscle strength, balance disorder, multiple sclerosis relapse, tingling or numbness in the extremities, nose or throat inflammation, constipation, upset stomach, and throat pain. Avoid concomitant use of ampyra with other forms of 4 aminopyridine 4ap. Ampyra can cause a seizure convulsions, even if you have never had one before. If the patient has primary progressive ms or a relapsing form of ms, one of the following. Just fill out this form and bring it to your health care professional. Ampyra dalfampridine is a potassium channel blocker. I wish you continued success with ampyra and please know your posts are very helpful and hopeful lynn ps. Here are average copays for some of the most popular medicare plans. As in controlled clinical trials, a dosedependent increase in the incidence of seizures has been observed in openlabel clinical trials with ampyra in patients with ms as follows. Food and drug administration fda to help improve walking in adults with multiple sclerosis ms. Ampyra should not be taken with other forms of 4aminopyridine 4.
Page 1 of 5 instructions for health care providers. Ampyra may cause serious side effects, including severe allergic reactions. Ampyra will be approved when all of the following are met. Getting started on aubagio teriflunomide for relapsing ms. In patients with mild renal impairment crcl 5180 mlmin, ampyra plasma levels may approach those seen at a dose of 15 mg twice daily, a dose that is 1.
Indication ampyra dalfampridine extended release tablets, 10 mg, is the first and only brand medication indicated to improve walking in adults with multiple. Ampyra is a prescription medicine used to improve walking in adults with multiple sclerosis ms. Ampyra is contraindicated in patients with history of seizure, moderate or severe renal impairment crcl. Ampyra is the brand name of the generic drug dalfampridine, which is used to improve walking in people with multiple sclerosis ms ms is a disease that causes weakness, numbness, loss of. Dec 20, 2019 dosage in patients with renal impairment. Read the overview of one to one support services for aubagio on page 2. It is not known if ampyra is safe or effective in children less than 18 years old. Coverage authorization cri dalfampridine ampyra may be eligible for coverage when the following criteria are met. Patient name address city state zip home phone cell phone preferred time to call sex. The patient has a diagnosis of multiple sclerosis ms and ii.
Be sure to include your email address in the space provided. Fax pages 4 and 5 of the start form to 877 3122193. Physician confirmation that patient has difficulty walking. Side effects seen in clinical trials include urinary tract infection, insomnia, dizziness, headache, nausea, back pain, loss of muscle strength, balance disorder, multiple sclerosis relapse, tingling or numbness in the extremities, nose or throat inflammation, constipation, upset. Ampyra dalfampridine basics powered by improves walking in patients with ms multiple sclerosis. Authorization form on the last page of this document. This was demonstrated by an increase in walking speed. If i do not wish to receive information related to ampyra or any related products or services or to be contacted occasionally for market research purposes, i understand that i may call the ampyra patient support services centers tollfree number, 8888811918 at any time. Read this medication guide before you start taking ampyra and each time you get a refill. Oral medicine for ms walking problems, generic of ampyra, now. Ampyra michigan prior authorization request form please complete this entire form and fax it to. The patient is receiving concurrent therapy with a disease.
To start your part d coverage determination request, you or your representative or your doctor or. Tysabri natalizumab is indicated as monotherapy for the treatment of relapsing forms of multiple sclerosis, to include clinically isolated syndrome, relapsingremitting disease, and active secondary progressive disease, in adults. Ampyra dalfampridine is a potassium channel blocker indicated as a symptomatic treatment to improve walking in adult patients with multiple sclerosis ms. Ampyra dalfampridine extended release tablets, 10 mg is a prescription medicine approved by the u. Upmc health plan pharmacy services phone 800979upmc 8762 fax 4124547722 please type or print neatly please complete all sections of this form. Persons with disabilities having problems accessing the pdf files below may call 301 7963634 for assistance. Instructions for healthcare providers tecus0298 v9 0120.
Overall discontinuation rates due to adverse events were 12. Ampyra should not be taken with other forms of 4 aminopyridine. Aubagio one to one start form authorization to share health information as part of one to one support services please read this page carefully and if you agree, sign and date where indicated in section 2 of the start form. For your convenience, there are 3 ways to complete a prior authorization request. Ampyra should not be taken with other forms of 4aminopyridine 4ap, fampridine, since the active ingredient is the same. Avoid concomitant use with other forms of 4aminopyridine 4ap. Oral medicine for ms walking problems, generic of ampyra. In some cases, the medical and pharmacy cards may be the same. Ampyra dalfampridine extended release tablets company. Ampyra fda approved indications to improve walking in patients with multiple sclerosis ms. Ampyra dalfampridine enrollment form fax referral to. This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment.
You will receive a call from an ms one to one nurse. I am glad ampyra is helping you and i will ask my neuro about it next visit. I authorize biogen, and companies working with biogen, to contact me by mail, email, fax, telephone call, and text message including autodialed and prerecorded calls and messages for marketing purposes or otherwise provide me with information about biogens products, services, and programs or other topics of interest, conduct market research or otherwise ask me about my experience with or. Read the patient authorization information describing. Tell your doctor if you are pregnant or plan to become pregnant. Please note that email communications sent to acadia or its thirdparty service providers may not be encrypted or secured, and safeguards established under the hipaa security rule would not apply to these communications. Aubagio teriflunomide is indicated for the treatment of relapsing forms of multiple sclerosis ms, to include clinically isolated syndrome, relapsingremitting disease, and active secondary progressive disease, in adults. We may cover ampyra when the above criteria is met and with previous use of dalfampridine. We can start assisting you once this form is sent back to us by you or your health care provider on your behalf. Data sources include ibm watson micromedex updated 4 may 2020, cerner multum updated 4 may 2020. Page 4 can also be texted according to the instructions above. Find out how your ms patients respond to ampyra limitations and restrictions apply.