CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Polivy (polatuzumab vedotin) — coverage criteria

Defines indications, limits, coding, and prior authorization expectations for Polivy (polatuzumab vedotin) for members receiving care under Evolent-managed lines of business; applies to ordering providers submitting medication requests to Evolent.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPolivy (polatuzumab vedotin) — coverage criteria

Policy CodePolicy N/A

Change TypeTemplate conversion and supersedes prior guideline

Effective DateJun 1, 2025

Next Review DateN/A

Key ActionObtain prior authorization through Evolent documenting indication, line of therapy, and IPI score for first-line R-CHP requests.

SourceLink

POLICY UPDATE CHANGES

Converted to new Evolent guideline template and replaced prior UM ONC_1362 Polivy guideline; indication section and references were updated.

First-line IPI ≥2Covered initial therapy population

Single agent or w/ bendamustineSecond-line or subsequent therapy

J9309Billing code

≤1.8 mg/kgDose limit

≤6 cycles

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Coverage Criteria for Polivy (polatuzumab vedotin)

first-line

Covered when ALL of the following are met

First-line: Use in combination with R-CHP for patients with IPI >= 2IPI >= 2

First-line/initial therapy

Second-line or subsequent therapy

Covered when ANY of the following are met

Second-line or later: Member has diffuse large B-cell lymphoma (DLBCL) AND polatuzumab vedotin is requested as a single agent OR in combination with bendamustine, with or without rituximab/rituximab biosimilarN/A

Policy allows single-agent or bendamustine-containing regimens for later lines

second-line

Covered when ANY of the following are met

Second-line or subsequent: Use as single agent or with bendamustine, with or without rituximab for relapsed/refractory DLBCLN/A

Second-line or later

Coverage is not allowed when Polivy is being requested after disease progression on the same regimen or after prior exposure to Polivy or bendamustine unless the prior therapy was completed more than 1 year ago. Requests that exceed the policy dosing or duration limits — specifically a single dose > 1.8 mg/kg or treatment beyond 6 cycles — are also subject to denial. Providers submitting prior authorization requests should document prior therapies and dates of completion to demonstrate eligibility when prior Polivy or bendamustine was given.

Polivy use for off‑label indications that lack adequate supporting evidence is considered investigational and not approvable. Acceptable supporting evidence must be consistent with CMS‑recognized compendia or be provided in acceptable peer‑reviewed literature. When evaluating evidence the policy requires assessment of whether the patient and cancer characteristics, the administered regimen, and the reported outcomes are adequately represented; whether outcomes are clinically meaningful (for example, ASCO‑recommended thresholds such as a hazard ratio < 0.80 or at least a 3‑month survival benefit for OS/PFS); and whether the study design is appropriate. Single case reports or abstracts without a full peer‑reviewed publication generally do not meet the standard for supportive evidence.

Regimens and Indications

Regimen	Indication	Coverage
Polivy (polatuzumab vedotin) + R-CHP (rituximab + cyclophosphamide + doxorubicin + prednisone)
First-line/initial treatment for members with Diffuse Large B-Cell Lymphoma (DLBCL) or High-Grade B-Cell Lymphoma (HGBL) with International Prognostic Index (IPI) score ≥ 2
Covered

Regimen	Indication	Coverage
Polivy (polatuzumab vedotin) as single agent
Second-line or subsequent therapy for members with Diffuse Large B-Cell Lymphoma (DLBCL)
Covered

Billing and Coding

Covered HCPCS CodesHCPCSCovered

J9309

Injection, polatuzumab vedotin-piiq, 1 mg

inv-06: Single dose limit — ≤ 1.8 mg/kg

Single dose limitPolivy (polatuzumab vedotin) maximum single dose: ≤ 1.8 mg/kg

Consequence of exceeding limitDosing above 1.8 mg/kg is listed as an exclusion criterion and may lead to denial of coverage

Billing implicationProviders must calculate dose by patient weight to ensure per-dose limit is not exceeded

inv-07: Maximum treatment duration — ≤ 6 cycles

Maximum treatment durationPolivy (polatuzumab vedotin) maximum duration of therapy: ≤ 6 cycles

Consequence of exceeding limitTreatment beyond 6 cycles is listed as an exclusion criterion and may result in denial

Provider Actions, Prior Authorization, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior authorization required through Evolent for all requests. Evolent is responsible for processing medication requests from network ordering providers; medications not authorized by Evolent may be deemed not approvable and therefore not reimbursable. Requests must document the indication, line of therapy, and supporting evidence (FDA labeling, CMS-recognized compendia, NCCN or ASCO guidelines, or acceptable peer-reviewed literature). For first-line use in DLBCL/HGBL with R-CHP, include the International Prognostic Index (IPI) score when requesting authorization.

Prior authorization required via Evolent
Include indication, line of therapy, and supporting evidence
For first-line DLBCL/HGBL with R-CHP include IPI score

Documentation Required

Continuation Allowance Conditions

Continuation requests for medications that would otherwise be not-approvable may be authorized only if all of the following are met: the member has not experienced disease progression on the requested medication; the requested medication was used within the last year without a lapse of more than 30 days of having an active authorization; and no additional medications are being added to the continuation request. If these conditions are not met, continuation is subject to standard medical necessity review and may be denied.

Definitions and Scoring

inv-13: International Prognostic Index (IPI) used to stratify DLBCL patients; policy requires IPI ≥2 for first-line use with R-CHP.

DefinitionInternational Prognostic Index (IPI) — a clinical score used to stratify risk in DLBCL patients

First-line requirementPolicy requires IPI score ≥ 2 for use of Polivy in combination with R-CHP as first-line/initial therapy

Regimen contextApplies specifically when Polivy is ordered with R-CHP (rituximab + cyclophosphamide + doxorubicin + prednisone)

PopulationApplies to members with Diffuse Large B-Cell Lymphoma (DLBCL) or High-Grade B-Cell Lymphoma (HGBL) being considered for first-line therapy

Background

Polatuzumab vedotin (Polivy) is an antibody–drug conjugate indicated for use in diffuse large B‑cell lymphoma (DLBCL) and high‑grade B‑cell lymphoma (HGBL) as part of front‑line and later‑line regimens per the policy. In first‑line therapy Polivy is covered only when given in combination with R‑CHP for patients with an International Prognostic Index (IPI) score ≥ 2. For relapsed or refractory disease, Polivy is covered as a single agent or in combination with bendamustine, with or without rituximab. Operational limits include a maximum single dose of 1.8 mg/kg and a maximum treatment duration of 6 cycles, and use after progression on the same regimen or after prior Polivy or bendamustine is restricted unless prior therapy was completed > 1 year ago.