Ponvory (ponesimod) — CareFirst (Caremark)
Relapsing forms of multiple sclerosis (including relapsing-remitting and active secondary progressive disease)
Initial criteria
- Member has a diagnosis of a relapsing form of multiple sclerosis (including relapsing-remitting or secondary progressive disease with continued relapses) OR clinically isolated syndrome of multiple sclerosis
- Medication is prescribed by or in consultation with a neurologist
- Member will not use Ponvory concomitantly with other disease-modifying multiple sclerosis agents (Ampyra and Nuedexta are not considered disease-modifying agents)
- Authorization may be granted for pediatric members age < 18 years when benefits outweigh risks
Reauthorization criteria
- Member is experiencing disease stability or improvement while receiving Ponvory
Approval duration
12 months