Ponvory — Cigna

multiple sclerosis

Preferred products

Patient meets BOTH of the following (A and B):
A) Patient meets the standard Multiple Sclerosis – Ponvory Prior Authorization Policy criteria; AND
B) Patient meets ONE of the following (i or ii):
i. Patient has been established on Ponvory for ≥ 120 days; OR
ii. Patient meets BOTH of the following (a and b):
a) Patient meets BOTH of the following [(1) and (2)]:
(1) Patient has tried generic dimethyl fumarate delayed-release capsules [documentation required]; AND
(2) Patient has experienced inadequate efficacy or significant intolerance according to the prescriber [documentation required];
b) Patient meets BOTH of the following [(1) and (2)]:
(1) Patient has tried generic fingolimod capsules [documentation required]; AND
(2) Patient has experienced inadequate efficacy or significant intolerance according to the prescriber [documentation required].

1 year