CurrentNeighborhood Health Plan of Rhode IslandPolicy 3095-A

Polivy (polatuzumab vedotin-piiq)

Defines covered indications, authorization duration, and continuation criteria for polatuzumab (Polivy) across FDA-approved and compendial B-cell lymphoma indications, including specifics for combinations (e.g., with bendamustine/rituximab, R-CHP) and use as bridging therapy or with mosunetuzumab. Excludes non-listed indications as investigational.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPolivy (polatuzumab vedotin-piiq)

Policy CodePolicy 3095-A

Change TypeNo material change

Effective Date

Next Review Date

Key ActionAuthorization is required and may be granted for up to 6 months (up to 6 cycles) when criteria are met; reauthorization requires no unacceptable toxicity, no disease progression, and fewer than 6 prior cycles received.

SourceLink

POLICY UPDATE CHANGES

No material changes — policy remains current with prior criteria and coverage stance.

7Covered B-cell lymphoma subtypes explicitly listed

6 cyclesMaximum authorization

>=2Prior therapies required for one FDA indication

Coverage Summary & Eligible Indications

Background: Polivy (polatuzumab vedotin-piiq) is an antibody‑drug conjugate indicated for multiple B‑cell lymphomas; coverage follows the FDA label and compendial uses when all authorization criteria are met.

Scope summary / coverage stance: Polivy is covered with criteria for FDA‑approved indications and for specified compendial B‑cell lymphoma subtypes when the listed authorization criteria are satisfied. FDA‑approved uses include Polivy in combination with bendamustine and a rituximab product for relapsed or refractory DLBCL after at least two prior therapies, and Polivy with R‑CHP for previously untreated DLBCL or HGBL with an IPI score of 2 or greater (FDA indications). Compendial B‑cell lymphoma uses listed (e.g., HGBL, PTLD B‑cell type, HIV‑related B‑cell lymphomas, histologic transformation to DLBCL or HGBL) are covered when the specific clinical criteria in the policy are met (examples: use as subsequent therapy when transplant is not an option or as bridging to CAR T, use with mosunetuzumab‑axgb, or first‑line R‑CHP with required IPI/MYC/BCL criteria).

FDA-Approved Indications

Covered when the FDA indication applies and approval criteria for the indication are met:

ANY of the following

FDA indication 1: Polivy in combination with bendamustine and a rituximab product for treatment of adult patients with relapsed or refractory DLBCL, not otherwise specified, after at least two prior therapies.
FDA indication 2: Polivy in combination with a rituximab product, cyclophosphamide, doxorubicin, and prednisone (R-CHP) for treatment of adult patients with previously untreated DLBCL, NOS or HGBL and who have an International Prognostic Index score of 2 or greater.

Continuation Therapy (Reauthorization)

Continuation of Therapy (Reauthorization)

Authorization up to 6 months (6 cycles total) may be granted for continued treatment when ALL criteria below are met:

ALL of the following

Member is requesting reauthorization for an indication listed in the coverage criteria section.
There is no evidence of unacceptable toxicity while on the current regimen.
There is no evidence of disease progression while on the current regimen.
Member has not received 6 or more cycles of the requested drug.

Authorization thresholds

Authorization durationUp to 6 months (up to 6 cycles)

Prior therapies for relapsed/refractory DLBCL (FDA)After at least two prior therapies

IPI threshold — some first-line R-CHP usesGreater than 1

IPI threshold — FDA R-CHP indication2 or greater

Not Covered / Investigational Uses

Not Covered / Investigational

All other indications not listed above are considered:

ALL of the following

Experimental/investigational and not medically necessary.

Provider Actions & Documentation Requirements

Prior Authorization

Prior authorization required for covered uses

Authorization is required and may be granted for up to 6 months (up to 6 cycles) when criteria are met; reauthorization requires no unacceptable toxicity, no disease progression, and fewer than 6 prior cycles received.

Documentation Required

Clinical documentation of disease subtype and transplant candidacy/bridging rationale

Provider must document lymphoma subtype, IPI score where required, prior therapies (e.g., at least two prior therapies when applicable), transplant candidacy or need for bridging to CAR T-cell therapy, and prior/current combination regimens (e.g., R-CHP, bendamustine/rituximab, mosunetuzumab).

Lymphoma subtype (e.g., DLBCL, HGBL, PTLD, HIV-related, transformed disease)
International Prognostic Index (IPI) score when applicable (e.g., >1 or ≥2 per criteria)
Prior therapies received (e.g., at least two prior therapies for the relapsed/refractory DLBCL FDA indication)
Transplant candidacy or documentation that therapy is being used as bridging to CAR T-cell product
Planned or current combination regimen (e.g., R-CHP, bendamustine ± rituximab, mosunetuzumab-axgb)

Clinical Evidence and Background

Polivy is an antibody‑drug conjugate (polatuzumab vedotin‑piiq) referenced in the FDA package insert and the NCCN Drugs & Biologics Compendium.

Policy references and rationale for covered uses: The policy references the FDA label indications — Polivy with bendamustine + rituximab for relapsed/refractory DLBCL after at least two prior therapies, and Polivy with R‑CHP for previously untreated DLBCL or HGBL with an IPI score of 2 or greater — and extends coverage to specified compendial B‑cell lymphoma subtypes when authorization criteria are met. The listed covered uses reflect clinical contexts supported by compendia and the label: combination regimens (e.g., with bendamustine and/or rituximab, or R‑CHP), use as a bridging option to CAR T‑cell therapy for transplant‑ineligible members or when CAR T is pending, and use in combination with mosunetuzumab‑axgb for relapsed or refractory disease.

Clinical documentation expectations: Providers must document lymphoma subtype, IPI score where required, prior therapies (including >=2 prior therapies when applicable), transplant candidacy or need for CAR T bridging, and prior/current combination regimens (e.g., R‑CHP, bendamustine/rituximab, mosunetuzumab) to support authorization decisions.

Polivy package insert (April 2023); NCCN Drugs & Biologics Compendium (accessed April 18, 2025)