ModifiedCentenePolicy CP.PHAR.537

Ponesimod (Ponvory) for relapsing forms of multiple sclerosis

Centene policy governing medical necessity and prior authorization criteria for ponesimod (Ponvory) for treatment of relapsing forms of multiple sclerosis in adults across Commercial, HIM/ICHRA, and Medicaid lines of business.

Policy Summary

PayerCentene

PolicyPonesimod (Ponvory) for relapsing forms of multiple sclerosis

Policy CodePolicy CP.PHAR.537

Change TypeMaterial updates to authorization duration and step therapydocumentation requirements revised

Effective DateJun 1, 2021

Next Review Date

Key ActionSubmit prior authorization demonstrating diagnosis of a relapsing form of MS with supporting clinical documentation and ensure dosing follows the 14-day titration to a 20 mg/day maintenance dose.

SourceLink

POLICY UPDATE CHANGES

Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition and added ICHRA line of business.

Added step therapy bypass for Illinois HIM per IL HB 5395.

Removed requirements for documentation of baseline relapses/EDSS and specific measures of positive response.

Extended initial approval duration from 6 to 12 months for this maintenance medication for a chronic condition.

Requirements for documentation of baseline relapses/expanded disability status score and specific measures of positive response were removed.

12 monthsApproval duration for continued therapy

≥18Minimum age for coverage

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

20 mg/dayMaximum maintenance dose

14-dayTitration schedule

Commercial, HIM/ICHRA, MedicaidLines of business

2Q 2026Most recent review

Coverage Criteria

Initial Therapy

Covered when ALL of the following are met for Multiple Sclerosis:

MS initial: 1) Diagnosis of one of the following: a) Clinically isolated syndrome, b) Relapsing‑remitting MS, or c) Secondary progressive MS; for clinically isolated syndrome or relapsing‑remitting MS, step therapy failure of specified agents or contraindication/clinically significant adverse effects is required unless Illinois HIM bypass applies per IL HB 5395;

Step therapy agents referenced include dimethyl fumarate, teriflunomide, fingolimod, and an interferon‑beta agent or glatiramer as detailed in policy.

Prescriber & age: 2) Prescribed by or in consultation with a neurologist; 3) Member age ≥ 18 years.

Concomitant therapy: 4) Not prescribed concurrently with other disease‑modifying therapies for MS (see Appendix D).

Dosing and titration: 5) Request meets dosing requirements: initiation follows the 14‑day titration schedule and does not exceed 1 tablet per day; maintenance dose does not exceed 20 mg per day and 1 tablet per day.<= 20 mg/day

Titration schedule detailed in Dosage and Administration (Days 1–14) with maintenance 20 mg PO QD from Day 15 onward.

Continuation Therapy

Covered when ALL of the following are met for Continued Therapy:

Continuity: 1) Member meets one of the following: a) Currently receiving medication via the Centene benefit or previously met initial approval criteria; or b) Member is currently receiving medication and is enrolled in a state/product with continuity of care regulations.

Refer to state‑specific continuity of care addendums (CC.PHARM.03A/03B) where applicable.

Clinical response: 2) Member is responding positively to therapy.

Documentation (office notes, labs, or other clinical information) supporting response may be required.

Concomitant therapy continued: 3) Ponvory is not prescribed concurrently with other disease‑modifying therapies for MS (see Appendix D).

Dose change: 4) If request is for a dose increase, the new dose does not exceed 20 mg per day and 1 tablet per day.

The following diagnoses and indications are excluded from coverage under this policy unless an applicable off‑label use policy supports the request: non‑FDA approved indications. Requests for such non‑FDA uses must be supported by documentation of efficacy and safety consistent with the plan’s off‑label use policies (see CP.CPA.09 for Commercial, HIM.PA.154 for HIM/ICHRA, and CP.PMN.53 for Medicaid).

Additionally, primary progressive multiple sclerosis (primary progressive MS) is specifically listed as a diagnosis for which coverage is not authorized under this policy.

When there is a conflict between this clinical policy and a state Medicaid program’s coverage provisions, the state Medicaid coverage provisions take precedence. Providers and reviewers should follow the applicable state Medicaid manual for any state‑specific coverage rules that supersede this policy.

Use of ponesimod for primary progressive multiple sclerosis is not authorized and is considered not medically necessary under this policy.

Coding

No codes listed in this partmixed

No codes listed

inv-07: Maximum daily dose — 20 mg/day

Maximum daily dose20 mg/day (maintenance) — not to exceed 1 tablet per day

Titration schedule (initiation)14-day titration starting at 2 mg PO QD and reaching 10 mg PO QD on days 12-14

Maintenance dosingDay 15 and thereafter: 20 mg PO QD

Missed dose guidanceIf fewer than 4 consecutive doses missed: resume at appropriate titration or maintenance dose; if 4+ consecutive doses missed: reinitiate Day 1 of titration

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required. Requests must demonstrate a diagnosis of a relapsing form of multiple sclerosis and that the prescriber is a neurologist or has consulted with a neurologist. Prior authorization is required for initial and continued therapy.

Prior authorization required for initial and continued therapy
Prescriber is or consulted with a neurologist
Diagnosis must be a relapsing form of MS

Documentation Required

Provider must submit documentation (such as office chart notes, laboratory results, or other clinical information) supporting that the member has met all approval criteria. Failure to provide adequate documentation may result in denial or a request for additional information.

Acceptable documentation: office notes, lab results, other clinical information

Background

Ponesimod (Ponvory) is an oral sphingosine 1‑phosphate (S1P) receptor modulator indicated for the treatment of relapsing forms of multiple sclerosis in adults. It is used as a disease‑modifying therapy to reduce relapse risk and slow disability progression.

Initiation of ponesimod requires a 14‑day titration to reach the maintenance regimen, with a maximum maintenance dose of 20 mg per day administered as one tablet daily.

Definitions

inv-18: Relapsing forms of multiple sclerosis

FDA‑approved indication (short)Relapsing forms of multiple sclerosis — includes clinically isolated syndrome, relapsing‑remitting MS, and active secondary progressive MS

Age populationAdults (per FDA indication)

Clinical roleDisease‑modifying therapy to reduce relapse risk and disability progression

inv-19: Medicaid precedence

Priority of coverage for Medicaid membersState Medicaid coverage provisions take precedence when they conflict with this clinical policy — refer to the state Medicaid manual

ApplicabilityApplies only to Medicaid members when a conflict exists between this policy and state provisions

Policy Summary

PayerCentene

PolicyPonesimod (Ponvory) for relapsing forms of multiple sclerosis

Policy CodePolicy CP.PHAR.537

Change TypeMaterial updates to authorization duration and step therapydocumentation requirements revised

Effective DateJun 1, 2021

Next Review Date

SourceLink

On This Page

Approval duration: 12 months.

Initial approval duration was extended to 12 months in the 2Q 2026 review.

Documentation must show member meets all approval criteria

Documentation Required

Updated Documentation Expectations (after 2Q 2025)

Documentation expectations were updated in 2Q 2025. Requirements for documentation of baseline relapses, expanded disability status score (EDSS), and specific measures of positive response were removed. Continue to provide clinical information demonstrating the member meets approval criteria, but the prior baseline relapse and EDSS documentation requirements are no longer required.

Removed: baseline relapses documentation
Removed: expanded disability status score (EDSS) documentation
Removed: specific measures of positive response

Step Therapy

Step Therapy / Step Edits

Step therapy (failure or contraindication) is required for certain MS diagnoses. For relapsing‑remitting MS, failure of or contraindication to dimethyl fumarate, teriflunomide, fingolimod, and an interferon‑beta agent or glatiramer is required unless clinically significant adverse effects or contraindications exist. For clinically isolated syndrome there are step requirements related to interferon‑beta or glatiramer products as specified in policy.

Relapsing‑remitting MS: failure of dimethyl fumarate, teriflunomide, fingolimod, and an interferon‑beta agent or glatiramer at maximally indicated doses (unless intolerant or contraindicated)
Clinically isolated syndrome: contraindication or intolerance to specified interferon‑beta or glatiramer agents

Step Therapy

Step Therapy Bypass — Illinois (IL HIM)

Step therapy bypass for Illinois High‑Impact Medication (HIM): per IL HB 5395 (effective 1/1/2026), the step therapy requirements do not apply for Illinois HIM requests. Include state/product information to confirm applicability.

IL HIM step therapy bypass effective 1/1/2026 per IL HB 5395
Applicability: Illinois HIM requests only

Reference instructionConsult the state Medicaid manual for any coverage provisions pertaining to this clinical policy