PONVORY (ponesimod)

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.