Dosage & Administration Biomarker testing Drug label Prior authorization Pharmacy Financial assistance

Polivy

(polatuzumab vedotin)

polatuzumab vedotin-piiq 140 MG Injection [Polivy]polatuzumab vedotin-piiq 30 MG Injection [Polivy]

NO BLACK BOX WARNING

Dosage & administration

* The recommended dose of POLIVY is 1.8 mg/kg as an intravenous infusion over 90 minutes every 21 days for 6 cycles in combination with bendamustine and a rituximab product. 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.

biomarker testing

Polivy clinical details

Genetic testing requirements were obtained from the NCCN guidelines for each cancer type.

drug label

Polivy prescribing information

Contact Medical Science Liaison Report Adverse Event

prior authorization

Polivy prior authorization resources

Most recent Polivy prior authorization forms

View By Payer

Verified: Sep 28, 2023Cigna - Polivy Prior Authorization Form

Verified: Sep 21, 2023Aetna - Polivy Prior Authorization Form

Verified: Sep 21, 2023Aetna - Medicare Part B Polivy Prior Authorization Form

OTHERComplete Letter of Medical Necessity

OTHERCoverage Authorization Appeals

PDFPatient Consent Form

PDFPatient Consent Form - Spanish

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Benefits investigation

PDFPolivy Prescriber Service & Patient Consent Form

Phesgo Prescriber Service Form - Online Portal

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pharmacy

Polivy preferred pharmacy

OTHERPharmacy List

financial assistance

Polivy financial assistance options

Co-pay savings program

commercial only

PDFPolivy Prescriber Service & Patient Consent Form

Phesgo Prescriber Service Form - Online Portal

Enroll in Patient Savings Program

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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

under insured

no insurance

goverment insurance

65+

PDFPolivy Prescriber Service & Patient Consent Form

Phesgo Prescriber Service Form - Online Portal

PDFGenentech Patient Foundation Application Form (1/2)

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

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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 co-pays) 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

Getting started on Polivy

To share resource; ask patient to:

1.Pull out phone

2.Open camera

3.Scan QR code with camera

4.Tap link