Pediatric patient at least 1 year old Diagnosis of tuberous sclerosis complex (TSC) with subependymal giant cell tumor that is unresectable Ampyra May be approved when the following criteria are met: Initial Approval: Last reviewed: 10/22/2015 Prescribed by, or in consultation with a neurologist 2 months Patient is between 18 and 70 years old Diagnosis of multiple sclerosis with impaired walking ability defined as a baseline 25-ft Renewal: walking test between 8 and 45 seconds OR Expanded Disability Status Scale (EDSS) between 1 year 4.5 and 6.5 Requires: Patient is stabilized on disease modifying therapy for MS (i.e., no recent exacerbations) At least 20% improvement Patient is NOT wheelchair-bound in timed walking speeds on Patient does not have a history of seizures 25-ft walk within 4 weeks Patient does not have moderate to severe renal impairment (Crcl < 50 ml/min) of starting medication Note: Less than 50% of patients respond to treatment Antidementia For Patients who meet all of the following: Initial Approval: donepezil 5mg,10mg, - Indefinitely galantamine, -ER, Diagnosis of Alzheimer’s disease Namenda, rivastigmine Potential causes for cognitive dysfunction. (eg, cerebrovascular disease, cobalamin [vitamin capsules B-12] deficiency, syphilis, thyroid disease) has beeen ruled out. Cognitive assessment to evaluate for the presence of dementia; Mini-Mental Status Exam (MMSE) score below 22 OR Mini-Cog score of 2 and abnormal CDT (clock drawing test) ≤ Age restriction: must be at least 18 years old ARBs For patients who meet the following: Initial Approval: Benicar Prescribed by a cardiologist OR Indefinite
Pediatric patient at least 1 year old Diagnosis of tuberous sclerosis complex (TSC) with subependymal giant cell tumor that is unresectable Ampyra Last reviewed: 10/22/2015 May be approved when the following criteria are met: Prescribed by, or in consultation with a neurologist Patient is between 18 and 70 years old Diagnosis of multiple sclerosis with impaired walking ability defined as a baseline 25-ft walking test between 8 and 45 seconds OR Expanded Disability Status Scale (EDSS) between 4.5 and 6.5 Patient is stabilized on disease modifying therapy for MS (i.e., no recent exacerbations) Patient is NOT wheelchair-bound Patient does not have a history of seizures Patient does not have moderate to severe renal impairment (Crcl < 50 ml/min) Initial Approval: 2 months Renewal: 1 year Requires: At least 20% improvement in timed walking speeds on 25-ft walk within 4 weeks of starting medication Note: Less than 50% of patients respond to treatment Antidementia donepezil 5mg,10mg, galantamine, -ER, Namenda, rivastigmine capsules For Patients who meet all of the following: Diagnosis of Alzheimer’s disease Potential causes for cognitive dysfunction. (eg, cerebrovascular disease, cobalamin [vitamin B-12] deficiency, syphilis, thyroid disease) has beeen ruled out. Cognitive assessment to evaluate for the presence of dementia; Mini-Mental Status Exam (MMSE) score below 22 OR Mini-Cog score of ≤ 2 and abnormal CDT (clock drawing test) Age restriction: must be at least 18 years old Initial Approval: Indefinitely ARBs Benicar For patients who meet the following: Prescribed by a cardiologist OR Initial Approval: Indefinite -