PONVORY (ponesimod)

Self Administration - oral tablet

 

Diagnosis considered for coverage:
  • Relapsing forms of multiple sclerosis (MS):  Indicated for the treatment of relapsing forms of multiple sclerosis (MS), to include clinically isolated syndrome, relapsing-remitting disease, and active secondary progressive disease, in adults.

 

Coverage Criteria:

For diagnosis of multiple sclerosis (MS):

  • Patient has a documented diagnosis of relapsing forms of MS (e.g., clinically isolated syndrome, relapsing-remitting disease, secondary progressive disease, including active disease with new brain lesions) AND
  • Not used in combination with another disease-modifying therapy for MS AND
  • Prescribed by or in consultation with a neurologist; AND
  • One of the following: 
    • Failure after a trial of at least 4 weeks, contraindication, or intolerance to at least two of the following disease-modifying therapies for MS:
      • Avonex, Rebif, or Rebif Rebidose (interferon beta-1a)
      • Betaseron (interferon beta-1b)
      • Copaxone/Glatopa (glatiramer acetate)
      • Dimethyl fumarate
      • Vumerity (diroximel fumarate)
      • Plegridy (peginterferon β-1a)
      • Kesimpta (ofatumumab) OR
    • For continuation of therapy, as defined as no more than a 45-day gap in therapy

 

Reauthorization Criteria:

For diagnosis of MS:

  • Documentation of positive clinical response to therapy (e.g., stability in radiologic disease activity, clinical relapses, disease progression).

 

Dosing: 

For diagnosis of MS:

  • Initiate with a 14-day titration
  • Maintenance daily dose: 20mg

 

Coverage Duration:
  • Initial: 1 year
  • Reauthorization: 1 year

 

Authorization is not covered for the following:
  • The use of this drug for indications not listed in this policy does not meet the coverage criteria established by the Western Health Advantage (WHA) Pharmacy and Therapeutics (P&T) Committee.

 

Additional Information:
  • You must use the Ponvory Starter Pack to slowly increase the dose over a 14-day period to help reduce the effect of slowing of your heart rate.
  • If four (4) or more consecutive doses are missed during titration or maintenance treatment should be reinitiated with Day 1 of the titration regimen (new starter pack).

 

Policy Updates:
  • 08/16/2022 - coverage criteria approved by P&T committee.
  • 6/1/2024 (policy effective date)- RRT MS update, added DSE to include Kesimpta (P&T 
    5/20/2024) (P&T Meeting May)

 

References:
  1. Ponvory tablets [prescribing information]. Titusville, NJ: Janssen; April 2021.

 

 

Last review date: June 1, 2024

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