Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
Polatuzumab vedotin-piiq (Polivy) may be considered medically necessary in individuals 18 years of age and older for the following:
Diffuse Large B-Cell Lymphoma (DLBCL)
- For the treatment of relapsed or refractory diffuse large B cell lymphoma (DLBCL) when ALL of the following criteria are met:
- Given in combination with bendamustine and a rituximab product; and
- Documentation of diagnosis of DLBCL; and
- Documentation of at least two (2) prior therapies; and
- Administration of prophylaxis for Pneumocystis jiroveci pneumonia and herpes virus throughout treatment with polatuzumab vedotin (Polivy).; or
- For the treatment of previously untreated DLBCL, not otherwise specified or high-grade B-cell lymphoma (HGBL) when ALL the following criteria are met:
- Individual has International Prognostic Index score of 2 or greater; and
- Given in combination with a rituximab product, cyclophosphamide, doxorubicin, and prednisone (R-CHP); and
- Administration of prophylaxis for Pneumocystis jiroveci pneumonia and herpes virus throughout treatment with polatuzumab vedotin (Polivy); or
Compendia Sources
Polatuzumab vedotin (Polivy) may be considered medically necessary for treatment of any of the current category 1 or 2A NCCN recommendations
The use of polatuzumab vedotin (Polivy) not meeting the criteria as indicated in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature.
Procedure Codes
