Polivy Prescribing & Dosing Schedule

Dosage & Administration Drug label Prior authorization Pharmacy Financial assistance Patient education People also ask

Polivy (polatuzumab vedotin-piiq)

Polivy 30 MG Injection

NO BOXED WARNING

Dosage & Administration

* The recommended dose of POLIVY is 1.8 mg/kg as an intravenous infusion every 21 days for 6 cycles.
* Administer the initial POLIVY dose over 90 minutes. Subsequent infusions may be administered over 30 minutes if the previous infusion is tolerated.
* Premedicate with an antihistamine and antipyretic before POLIVY.
* See Full Prescribing Information for instructions on preparation and administration.

drug label

Polivy Prescribing Information

Contact Medical Science Liaison

Report Adverse Event

prior authorization

Polivy Prior Authorization Resources

Most recent state uniform prior authorization forms

Verified: Jun 26, 2024Arizona - Uniform Prior Authorization Form

Verified: Jun 26, 2024Colorado - Uniform Prior Authorization Form

Verified: Jun 26, 2024Hawaii - Uniform Prior Authorization Form

Verified: Jul 26, 2024Illinois - Uniform Prior Authorization Form

Verified: Jun 26, 2024Indiana - Uniform Prior Authorization Form

Verified: Jun 26, 2024Louisiana - Uniform Prior Authorization Form

Verified: Jun 26, 2024Minnesota - Uniform Prior Authorization Form

Verified: Jun 26, 2024New Hampshire - Uniform Prior Authorization Form

Verified: Jun 26, 2024New Mexico - Uniform Prior Authorization Form

Verified: Jun 26, 2024Oregon - Uniform Prior Authorization Form

Verified: Jun 26, 2024Texas - Uniform Prior Authorization Form

Verified: Jul 07, 2024Washington - Uniform Prior Authorization Form

Verified: Jul 07, 2024Wisconsin - Uniform Prior Authorization Form

Complete Letter of Medical Necessity

Coverage Authorization Appeals

Patient Consent Form

Patient Consent Form - Spanish

Benefits investigation

Polivy Prescriber Service & Patient Consent Form

Phesgo Prescriber Service Form - Online Portal

pharmacy

Polivy Preferred Pharmacy

Pharmacy List

financial assistance

Polivy Financial Assistance Options

Copay savings program

Polivy Prescriber Service & Patient Consent Form

Phesgo Prescriber Service Form - Online Portal

Enroll in Patient Savings Program

Learn More

Overview

Reduce patient OOP costs for drug (and occasionally for drug administration/infusion costs or drug-related test costs)

Patient benefit

A portion (or all) of patient OOP (deductible, copay), typically up to monthly and/or annual max

Patient eligibility

Patient must enroll or activate (may permit HCPs to enroll on patient’s behalf for HCP-administered drugs)
Generally, must have commercial insurance (rarely, may permit uninsured patients to use)
May never be used with government insurance

How to sign up

Cards may be downloadable digital cards or hard copies
Some pharmacos offer debit cards with pre-loaded copay benefit
Typically, available through multiple channels (e.g., rep to HCP to patient; pharmacy to patient; patient via website, Hub live agent, or copay vendor (live agent or IVR); patient and HCP via Hub enrollment form)
Some HCP-administered product programs permit HCPs to enroll on a patient’s behalf through via Hub form

Foundation programs

Polivy Prescriber Service & Patient Consent Form

Phesgo Prescriber Service Form - Online Portal

Genentech Patient Foundation Application Form (1/2)

Genentech Patient Foundation Application Form (2/2) - Patient Consent Form

Learn More

Overview

Charitable 501(c)(3) organizations provide direct cost-sharing and other support (e.g., travel, counseling) through disease-state funds to indigent patients on first-come first-served basis
These organizations may receive financial contributions from drug manaufacturers for particular disease-state funds that cannot provide funds directly to patients - the foundation must be independent/unaligned

Patient benefit

Patients apply for grants that cover a portion (or all) of their out-of-pocket costs (deductibles and copays) until the grant is exhausted

Patient eligibility

Patients must apply and meet eligibility criteria including income level (typically a multiple of federal poverty line), specific diagnosis, insurance status, etc.

How to sign up

Patients submit proof of out-of-pocket drug costs to charities for reimbursement

patient education

Polivy Patient Education

To share resource; ask patient to:

1.Pull out phone

2.Open camera

3.Scan QR code with camera

4.Tap link