Ponvory (ponesimod) — Highmark
Relapsing forms of multiple sclerosis (clinically isolated syndrome, relapsing-remitting disease, active secondary progressive disease)
Preferred products
- generic fingolimod
- generic dimethyl fumarate
Initial criteria
- age ≥ 18 years
- Diagnosis of multiple sclerosis (ICD-10: G35) classified as clinically isolated syndrome OR relapsing remitting disease OR active secondary progressive disease
- If new start to Ponvory, member has experienced therapeutic failure, contraindication, or intolerance to one of the plan-preferred products (generic fingolimod OR generic dimethyl fumarate)
Reauthorization criteria
- Prescriber attests that the member has experienced a therapeutic response defined as disease stability OR disease improvement OR delayed disease progression
Approval duration
24 months