12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra]
dalfampridine
RxCUI: 897025
What the CMS Formulary Data Shows for 12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra]
Per the CMS 2026 Part D formulary file, 12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra] (RxNorm concept RXCUI 897025, generic name dalfampridine) appears on 3 distinct formulary files spanning 17 Medicare Part D plan offerings - 0.3% of enrollable Part D products, selective placement; verify formulary inclusion before enrolling. Tier placement ranges from Tier 1 to Tier 5, with a cross-plan average of Tier 3.7.
Real-world access to 12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra] depends on utilization management as much as tier placement: 100% of covering formularies require prior authorization. 0% require step therapy. 66.7% apply quantity limits.
Historical spending context from the CMS Medicare Part D Drug Spending Dashboard shows 1,179 Part D beneficiaries filled 12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra] in 2023, with total plan-and-beneficiary spending of $44,351,232 and an average per-beneficiary annual cost of $37,617.67. The plan-by-plan detail below lists exactly which PDP and MA-PD contracts carry 12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra] today.
Coverage Details
- Formularies covering
- 3
- Plans covering
- 17
- Coverage rate
- 0.3%
- Tier range
- Tier 1 – Tier 5
- Average tier
- Tier 4, Non-Preferred
Restrictions
- Prior authorization required
- 100% of formularies
- Step therapy required
- 0% of formularies
- Quantity limits
- 66.7% of formularies
2023 Medicare Spending
- Beneficiaries
- 1,179
- Total spending
- $44,351,232
- Avg per beneficiary
- $37,617.67
Tier Distribution Across Plans
Medicare Advantage Plans (MA-PD) Covering 12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra]
17 Medicare Advantage plans with Part D drug coverage include this drug.
| Plan | Insurer | Tier | PA | Premium | States |
|---|---|---|---|---|---|
| Hamaspik Medicare Choice (HMO D-SNP) | HAMASPIK, INC. | T1 | Yes | $0 | NY |
| Hamaspik Medicare Select (HMO D-SNP) | HAMASPIK, INC. | T1 | Yes | $34.50 | NY |
| Personal Choice 65 Achieve Rx (PPO) | QCC INSURANCE COMPANY | T5 | Yes | $0 | PA |
| Keystone 65 Focus Rx (HMO-POS) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $0 | PA |
| Keystone 65 Focus Rx (HMO-POS) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $0 | PA |
| Keystone 65 Basic Rx (HMO) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $0 | PA |
| AmeriHealth Medicare Core (PPO) | AMERIHEALTH INSURANCE COMPANY OF NEW JERSEY | T5 | Yes | $0 | NJ |
| AmeriHealth Medicare Ultimate (PPO) | AMERIHEALTH INSURANCE COMPANY OF NEW JERSEY | T5 | Yes | $0 | NJ |
| Keystone 65 Essential Rx (HMO-POS) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $31.00 | PA |
| AmeriHealth Medicare Enhanced (PPO) | AMERIHEALTH INSURANCE COMPANY OF NEW JERSEY | T5 | Yes | $36.00 | NJ |
| Keystone 65 Select Rx (HMO) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $47.00 | PA |
| Keystone 65 Preferred Rx (HMO) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $59.70 | PA |
| Keystone 65 Select Rx (HMO) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $63.50 | PA |
| Keystone 65 Preferred Rx (HMO) | KEYSTONE HEALTH PLAN EAST, INC. | T5 | Yes | $79.70 | PA |
| Personal Choice 65 Plus Rx (PPO) | QCC INSURANCE COMPANY | T5 | Yes | $81.20 | PA |
| Personal Choice 65 Rx (PPO) | QCC INSURANCE COMPANY | T5 | Yes | $102.20 | PA |
| Personal Choice 65 Rx (PPO) | QCC INSURANCE COMPANY | T5 | Yes | $112.70 | PA |
Frequently Asked Questions
Is 12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra] covered by Medicare Part D?
Yes, 12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra] is covered by 17 Medicare Part D plans (0.3% of all Part D formularies).
What tier is 12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra] on Medicare Part D plans?
12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra] averages Tier 3.7 across Part D plans, ranging from Tier 1 to Tier 5.
Does 12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra] require prior authorization?
100% of Part D formularies require prior authorization for 12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra]. Step therapy: 0%. Quantity limits: 66.7%.
How much does Medicare spend on 12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra]?
In 2023, total Medicare Part D spending on 12 HR dalfampridine 10 MG Extended Release Oral Tablet [Ampyra] was $44,351,232, covering 1,179 beneficiaries. The average spend per beneficiary was $37,617.67.
Read our methodology - how this data is sourced, computed, and verified.