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:
- Ponvory tablets [prescribing information]. Titusville, NJ: Janssen; April 2021.
Last review date: August 16, 2022