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Polivy
State of North Carolina (MCO)
State of North Carolina (MCO) Coverage for Polivy
All
5
Commercial
2
Medicare
1
State Medicaid
2
Commercial
Commercial - PPO
PA Required
No Step Therapy
No Quantity Limit
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Commercial - Employer
PA Required
No Step Therapy
No Quantity Limit
See Details
Medicare
Medicare - Medicare Advantage Part D
PA Required
No Step Therapy
Quantity Limit
See Details
State Medicaid
State Medicaid - State Medicaid
No PA
No Step Therapy
No Quantity Limit
See Details
State Medicaid - AIDS Drug Assistance Program
No PA
No Step Therapy
No Quantity Limit
See Details
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