Dosage & Administration Drug label Prior authorization Financial assistance

Ampyra

(dalfampridine)

12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra]

NO BLACK BOX WARNING

Dosage & administration

* The maximum recommended dosage is 10 mg twice daily (approximately 12 hours apart). There is no evidence of additional benefit with doses greater than 10 mg twice daily. Adverse reactions, including seizures, were more frequent at higher doses. ( 2.1)
* Take with or without food. Administer tablets whole; do not divide, crush, chew, or dissolve. ( 2.2)
* Patients should not take double or extra doses if they miss a dose. ( 2.2)
* Estimated creatinine clearance (CrCl) should be known before initiating treatment with AMPYRA. In patients with mild renal impairment (CrCl 51–80 mL/min), AMPYRA may reach plasma levels associated with a greater risk of seizures, and the potential benefits of AMPYRA should be carefully considered against the risk of seizures in these patients ( 2.3, 5.2, 8.6)

Ampyra prescribing information

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prior authorization

Ampyra Prior authorization resources

NOT PROVIDED BY BRANDComplete Letter of Medical Necessity

NOT PROVIDED BY BRANDCoverage Authorization Request

NOT PROVIDED BY BRANDCoverage Authorization Appeals

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Benefits investigation

NOT PROVIDED BY BRANDBenefits investigation resources

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Reimbursement help (FRM)

NOT PROVIDED BY BRANDReimbursement help (FRM) resources

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financial assistance

Ampyra Financial assistance options

Co-pay savings program

commercial only

Enroll in patient savings program

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Overview

Reduce patient OOP costs for drug (and occasionally for drug administration/infusion costs or drug-related test costs)

Patient benefit

A portion (or all) of patient OOP (deductible, copay), typically up to monthly and/or annual max

Patient eligibility

Patient must enroll or activate (may permit HCPs to enroll on patient’s behalf for HCP-administered drugs)
Generally, must have commercial insurance (rarely, may permit uninsured patients to use)
May never be used with government insurance

How to sign up

Cards may be downloadable digital cards or hard copies
Some pharmacos offer debit cards with pre-loaded copay benefit
Typically, available through multiple channels (e.g., rep to HCP to patient; pharmacy to patient; patient via website, Hub live agent, or copay vendor (live agent or IVR); patient and HCP via Hub enrollment form)
Some HCP-administered product programs permit HCPs to enroll on a patient’s behalf through via Hub form

Bridge program

commercial only

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Overview

Provide patient immediate access to therapy during an insurance delay (typically new starts; some may cover change in insurance)
Limited time/ fill (typically 7-30 days; some may offer additional fill for continued delay up to certain limit)

Patient benefit

100% free (outside of insurance)

Patient eligibility

HCP must enroll patient
May be limited to commercially insured patients (i.e., no government beneficiaries); some programs may allow government beneficiaries

How to sign up

Typically HCP assisted enrollment (via form)

Foundation programs

under insured

no insurance

goverment insurance

65+

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Overview

Charitable 501(c)(3) organizations provide direct cost-sharing and other support (e.g., travel, counseling) through disease-state funds to indigent patients on first-come first-served basis
These organizations may receive financial contributions from drug manaufacturers for particular disease-state funds that cannot provide funds directly to patients - the foundation must be independent/unaligned

Patient benefit

Patients apply for grants that cover a portion (or all) of their out-of-pocket costs (deductibles and co-pays) until the grant is exhausted

Patient eligibility

Patients must apply and meet eligibility criteria including income level (typically a multiple of federal poverty line), specific diagnosis, insurance status, etc.

How to sign up

Patients submit proof of out-of-pocket drug costs to charities for reimbursement

patient education

Ampyra Patient education

Getting started on Ampyra

NOT PROVIDED BY BRANDInstructions For Use - (walking diffculties related to ) Multiple Sclerosis

Patient toolkit

About Ampyra

ASK PATIENT TO:
Open Camera on Phone
Scan QR Code & Tap Link

Patient Stories

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Ampyra FAQs

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Please note:

Access to a Field Reimbursement Manager (FRM) or Medical Science Liaison (MSL) varies by brand and may require talking with your rep first.
Samples are provided at the discretion of the brand.
We are unable to collect Protected Health Information (PHI), fill out forms, or submit them on your behalf.

Ampyra

Dosage & administration

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drug label

Ampyra prescribing information

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prior authorization

Ampyra Prior authorization resources

Benefits investigation

Reimbursement help (FRM)

financial assistance

Ampyra Financial assistance options

Co-pay savings program

Overview

Patient benefit

Patient eligibility

How to sign up

Bridge program

Overview

Patient benefit

Patient eligibility

How to sign up

Foundation programs

Overview

Patient benefit

Patient eligibility

How to sign up

patient education

Ampyra Patient education

Getting started on Ampyra

Patient toolkit

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Ampyra FAQs

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