Currentmedical mutual - ohioPolicy N/A

Ponvory (ponesimod)

Prior authorization policy governing pharmacy benefit coverage of Ponvory (ponesimod) for adult patients with relapsing forms of multiple sclerosis, including initial and continuation (≥1 year) approval criteria, documentation expectations, contraindicated/ not recommended uses, and prescriber requirements.

Policy Summary

Payermedical mutual - ohio

PolicyPonvory (ponesimod)

Policy CodePolicy N/A

Change TypeClarified (review date updated)

Effective Date

Next Review DateMay 22, 2025

Key ActionPrior authorization is recommended for Ponvory; ensure prescriptions are by or in consultation with a neurologist or MS specialist and provide documentation of response for continuation.

POLICY UPDATE CHANGES

Annual Review Date and Last Revised Date shown as 05/22/2025 in header.

2Approval durations (years)

3Relapsing MS types listed

2Continuation response pathways

Coverage Summary

This prior authorization policy governs pharmacy benefit coverage of Ponvory (ponesimod) for adult patients with relapsing forms of multiple sclerosis. It includes separate recommended criteria for initial therapy (age ≥18, diagnosis of a relapsing form, and prescribed by or in consultation with a neurologist or MS specialist) and for continuation therapy after ≥1 year (documentation of a beneficial clinical response by at least one objective measure or stabilization/improvement in symptoms, and continued specialist prescribing). The policy specifies required documentation and that the Company may request records, test results, and provider credentials to support medical necessity; it also lists conditions not recommended for approval (including concurrent use with other disease-modifying MS agents and non‑relapsing MS) and provides standard initial and extended approval durations.

Initial Therapy Criteria (Multiple Sclerosis)

Multiple Sclerosis; Initial Therapy

Covered when ALL of the following are met:

ALL of the following

Patient has a relapsing form of multiple sclerosis
Examples of relapsing forms include clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease
clarifying examples
Patient is 18 years of age or older
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

Initial Approval / Extended Approval Durations

ALL of the following

Initial Approval duration: 1 year
Extended Approval duration: 1 year

Continuation Therapy Criteria (Currently Receiving Ponvory ≥1 Year)

Multiple Sclerosis; Patient is Currently Receiving Ponvory for ≥ 1 Year (Continuation Therapy)

ALL of the following

ONE of
- Patient experienced a beneficial clinical response when assessed by at least one objective measure
  Examples include stabilization or reduced worsening in disease activity as evaluated by magnetic resonance imaging (MRI) [absence or a decrease in gadolinium enhancing lesions, decrease in the number of new or enlarging T2 lesions]; stabilization or reduced worsening on the Expanded Disability State Scale (EDSS) score; achievement in criteria for No Evidence of Disease Activity-3 (NEDA-3) or NEDA-4; improvement on the fatigue symptom and impact questionnaire-relapsing multiple sclerosis (FSIQ-RMS) scale; reduction or absence of relapses; improvement or maintenance on the six-minute walk test or 12-Item MS Walking Scale; improvement on the Multiple Sclerosis Functional Composite (MSFC) score; and/or attenuation of brain volume loss.
- Patient experienced stabilization, slowed progression, or improvement in at least one symptom such as motor function, fatigue, vision, bowel/bladder function, spasticity, walking/gait, or pain/numbness/tingling sensation
Medication is prescribed by or in consultation with a neurologist or a physician who specializes in the treatment of multiple sclerosis

Unproven / Exclusions (Not Recommended for Approval)

Conditions Not Recommended for Approval

Not recommended when ANY of the following apply:

ANY of the following

Concurrent use with other disease-modifying agents used for multiple sclerosis
These agents are not indicated for use in combination (See Appendix for examples). Additional data are required to determine if use of disease-modifying multiple sclerosis agents in combination is safe and provides added efficacy.
Non-relapsing forms of multiple sclerosis (e.g., primary progressive multiple sclerosis)
The effectiveness of Ponvory in patients with primary progressive multiple sclerosis has not been established.
Circumstances not listed in the Recommended Authorization Criteria
Requests for other uses will be reviewed case-by-case; coverage not recommended for circumstances not listed.

Provider Actions

Prior Authorization

Prior authorization recommended

Prior authorization is required for pharmacy benefit coverage of Ponvory. Approvals follow the policy’s specified coverage criteria and are granted for the durations noted in the Initial/Extended Approval section.

Documentation Required

Prescriber specialty requirement

Initial approval requires that Ponvory be prescribed by, or in consultation with, a neurologist or a physician who specializes in the treatment of multiple sclerosis.

Documentation Required

Continuation response documentation

Reauthorization after at least 1 year requires documentation that the patient experienced a beneficial clinical response or demonstrated stabilization, slowed progression, or improvement in symptoms based on objective measures or clinical assessment.

Stabilization or reduced worsening on MRI (absence or decrease in gadolinium‑enhancing lesions; decrease in new/enlarging T2 lesions)
Stabilization or reduced worsening on EDSS score
Achievement of NEDA‑3 or NEDA‑4 criteria
Improvement on FSIQ‑RMS; reduction or absence of relapses
Improvement/maintenance on six‑minute walk test or 12‑Item MS Walking Scale; improvement on MSFC; attenuation of brain volume loss

Documentation Required

Company may request additional documentation

The Company may request additional documentation to support medical necessity, including patient records, test results, and provider credentials. Failure to provide requested documentation may result in denial of coverage.

Denial Risk

Denial for off‑label or not medically necessary use

The Company may deny reimbursement when the drug use is not medically necessary, is investigational or experimental, is outside the member’s benefit coverage, or when there is a pattern of inappropriate or excessive billing.

Background & Definitions

Ponvory is a sphingosine 1-phosphate receptor modulator indicated for treatment of relapsing forms of multiple sclerosis in adults; the policy requires specialist involvement for prescribing and documents monitoring and response requirements for continuation of therapy.

Relapsing forms of multiple sclerosis: Includes clinically isolated syndrome, relapsing remitting disease, and active secondary progressive disease as noted in the policy.

NEDA-3 / NEDA-4: No Evidence of Disease Activity measures referenced as potential objective outcomes for response assessment.

Policy Summary

Payermedical mutual - ohio

PolicyPonvory (ponesimod)

Policy CodePolicy N/A

Change TypeClarified (review date updated)

Effective Date

Next Review DateMay 22, 2025

Key ActionPrior authorization is recommended for Ponvory; ensure prescriptions are by or in consultation with a neurologist or MS specialist and provide documentation of response for continuation.

On This Page

OpenPayer

Ponvory (ponesimod)

Coverage Summary

Initial Therapy Criteria (Multiple Sclerosis)

Continuation Therapy Criteria (Currently Receiving Ponvory ≥1 Year)

Unproven / Exclusions (Not Recommended for Approval)

Applicable Codes

Provider Actions

Clinical Evidence

Background & Definitions

Revision History