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)
  • Dose does not exceed 20 mg tablet once daily; AND
  • Patient is 18 years of age or older; AND
  • Prescribed by or in consultation with a neurologist; AND
  • Tried and failed 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)

 

Reauthorization Criteria:

 

For diagnosis of MS:

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

 

Coverage Duration:

 

  • Initial and reauthorization: One 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.

 

References:

 

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

 

 

Last review date: August 16, 2022