Ampyra For patients age 18 or older who meet all of the following criteria: Initial Approval: Prescribed by, or in consultation with a neurologist 6 months Patient is between 18 and 70 years old Documented diagnosis of multiple sclerosis with impaired walking ability Renewal: Patient must not be 1 year Baseline 25-ft walking test between 8 and 45 seconds Requires: Patient must not have a history of seizures At least 20% improvement Patient must not have moderate to severe renal impairment (Crcl < 50 ml/min) in timed walking speeds on Patient must be on disease modifying therapy for MS 25-ft walk within 4 weeks) Antidementia Drugs 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) 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 Edarbi 2 fills of a first-line agent (or any combination of first-line agents) in the last 130 days OR Documented intolerance to formulary ARBs Age restriction Benicar must be at trial 6 years old and weigh at least 20 kg – Edarbi must be at least 18 years old – First-line Agents include: ACE inhibitors Formulary ARBs:
Ampyra For patients age 18 or older who meet all of the following criteria: Prescribed by, or in consultation with a neurologist Patient is between 18 and 70 years old Documented diagnosis of multiple sclerosis with impaired walking ability Patient must not be Baseline 25-ft walking test between 8 and 45 seconds Patient must not have a history of seizures Patient must not have moderate to severe renal impairment (Crcl < 50 ml/min) Patient must be on disease modifying therapy for MS Initial Approval: 6 months Renewal: 1 year Requires: At least 20% improvement in timed walking speeds on 25-ft walk within 4 weeks) Antidementia Drugs 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) 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 Edarbi For patients who meet the following: Prescribed by a cardiologist OR 2 fills of a first-line agent (or any combination of first-line agents) in the last 130 days OR Documented intolerance to formulary ARBs Age restriction Benicar – must be at 6 years old and weigh at least 20 kg Edarbi – must be at least 18 years old First-line Agents include: ACE inhibitors Formulary ARBs: Initial Approval: Indefinite - trial
MMIC-PA-SMI-Guidelines.docx