CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Polivy (polatuzumab vedotin-piiq) — Coverage Criteria for B‑cell Lymphomas

Covers medical necessity and authorization criteria for Polivy (polatuzumab vedotin-piiq) in FDA-approved indications and specified compendial B‑cell lymphoma uses for members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyPolivy (polatuzumab vedotin-piiq) — Coverage Criteria for B‑cell Lymphomas

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization; approvals may be granted for up to 6 months (up to 6 cycles) when approval criteria and documentation are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 monthsauthorization duration

1L and R/R DLBCLcovered settings

Multiplecompendial uses

CAR Tbridging use

Coverage Criteria for Polivy (polatuzumab vedotin-piiq)

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

FDA‑approved indications

Relapsed/Refractory DLBCL (FDA): Polivy in combination with bendamustine and a rituximab product for adult patients with relapsed or refractory diffuse large B‑cell lymphoma (DLBCL), not otherwise specified, after at least two prior therapies.≥ 2 prior therapies
FDA‑approved indication; see product labeling.
First‑line DLBCL/HGBL (FDA): Polivy in combination with a rituximab product, cyclophosphamide, doxorubicin, and prednisone (R‑CHP) for previously untreated diffuse large B‑cell lymphoma (DLBCL), NOS, or high‑grade B‑cell lymphoma (HGBL) when the member has an International Prognostic Index (IPI) score of 2 or greater.IPI ≥ 2
FDA‑approved indication; see product labeling.

Compendial B‑cell lymphoma uses

DLBCL subsequent therapy (compendial): Requested drug used as subsequent treatment as a single agent, or in combination with bendamustine and/or rituximab for relapsed/refractory disease when the member is not a candidate for transplant, or the medication will be used as a bridging option until a CAR T‑cell product is available.transplant not candidate OR bridging to CAR T
Authorization guidance and bridging allowance per compendial section.
HGBL first‑line (compendial): Polivy + R‑CHP used as first‑line therapy for HGBL when the member has an IPI score greater than 1 and has MYC and BCL6 rearrangements without BCL2 rearrangement.IPI > 1 AND MYC+BCL6 without BCL2 rearrangement
Compendial criterion for selected HGBL subtypes.
Monomorphic PTLD (B‑cell type) and HIV‑related B‑cell lymphomas (compendial): Requested drug used as subsequent treatment as a single agent, or in combination with bendamustine and/or rituximab, and the member is not a candidate for transplant or the medication will be used as a bridging option until a CAR T‑cell product is available.transplant not candidate OR bridging to CAR T
Compendial allowance for PTLD and HIV‑related B‑cell lymphomas.
Histologic transformation to DLBCL or HGBL (compendial): For transformation of indolent lymphoma to DLBCL: Polivy used as subsequent treatment as a single agent or with bendamustine and/or rituximab when the member is not a candidate for transplant. For transformation to HGBL (MYC+BCL6 without BCL2): Polivy + R‑CHP as first‑line when IPI threshold met (IPI ≥ 2).transplant not candidate OR IPI ≥ 2 for R‑CHP use
Compendial criteria for transformed disease.

Continuation therapy

Continuation of therapy covered when ALL of the following are met

Continuation of therapy: There is no evidence of unacceptable toxicity or disease progression while on the current Polivy regimen AND the member has not received 6 or more cycles of Polivy.< 6 cycles and no progression/toxicity

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

Authorized Regimens and Uses

Regimen	Indication / Key criteria	Coverage status
Polivy + R‑CHP (polatuzumab vedotin-piiq with rituximab, cyclophosphamide, doxorubicin, prednisone)	First‑line therapy for previously untreated diffuse large B‑cell lymphoma (DLBCL, NOS) or high‑grade B‑cell lymphoma (HGBL) when member meets International Prognostic Index (IPI) thresholds (FDA: IPI ≥2; compendial: IPI >1 for certain HGBL subtypes) and, for specified HGBL, has MYC and BCL6 rearrangements without BCL2 rearrangement.	Covered

Regimen	Indication / Key criteria	Coverage status
Polivy as single agent or in combination with bendamustine and a rituximab product	Relapsed/refractory DLBCL and other compendial B‑cell lymphoma subtypes when used as subsequent therapy in members who are not candidates for transplant, or when used as a bridging therapy until a CAR T‑cell product is available. (FDA‑approved DLBCL indication requires ≥2 prior therapies.)	Covered

Drug Coding and Related Details

Drug referenceNDC | mixed

polatuzumab vedotin-piiq

POLIVY (polatuzumab vedotin-piiq)

International Prognostic Index (IPI) thresholds

IPI thresholds (general)International Prognostic Index (IPI) threshold varies by indication: greater than 1 for some first-line HGBL uses and IPI ≥2 for specified first-line DLBCL/HGBL or transformed disease

First-line DLBCL (FDA)IPI ≥2 required for Polivy + R-CHP in previously untreated DLBCL (NOS)

First-line HGBL (compendial)IPI >1 required for Polivy + R-CHP in first-line HGBL (double-/triple-hit) when MYC and BCL6 rearrangements are present without BCL2 rearrangement

Transformed indolent lymphomasIPI ≥2 required for use of Polivy + R-CHP in histologic transformation to DLBCL or HGBL per policy

Line of Therapy Criteria

first-line | second-line

First‑line: Polivy in combination with R‑CHP for previously untreated DLBCL (NOS) or HGBL when the member meets the required IPI threshold (e.g., IPI ≥ 2 for FDA first‑line indication; IPI >1 for certain HGBL compendial uses) and, when specified, requisite cytogenetic profile (MYC and BCL6 without BCL2 rearrangement).

See FDA and compendial criteria for IPI and cytogenetic requirements.

Second‑line / Subsequent (relapsed/refractory): Polivy as a single agent or in combination with bendamustine and/or rituximab for relapsed or refractory disease when the member is not a candidate for transplant, or when used as bridging therapy to a CAR T‑cell product. For FDA‑approved relapsed/refractory DLBCL use, member must have had at least two prior therapies.≥ 2 prior therapies for FDA relapsed/refractory DLBCL; transplant not candidate OR bridging to CAR T for compendial uses.

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization Required and Duration

Prior authorization is required. Authorization may be granted for up to 6 months (up to 6 cycles) for treatment of B‑cell lymphomas for the listed subtypes when criteria are met. Continuation/reauthorization may be approved up to a total of 6 cycles when there is no evidence of unacceptable toxicity or disease progression and the member has not already received 6 or more cycles.

Authorization duration: up to 6 months (up to 6 cycles).
Continuation: reauthorization allowed up to 6 cycles total if no unacceptable toxicity or disease progression and <6 cycles received to date.

Note

Subsequent Therapy Options

Polivy (polatuzumab vedotin-piiq) may be used as subsequent therapy options in relapsed or refractory B‑cell lymphomas as single-agent therapy or in combination with bendamustine and/or rituximab when the member is not a candidate for transplant or when used as a bridging therapy until a CAR T‑cell product is available. Additionally, for certain indications Polivy may be used as first‑line therapy in combination with rituximab, cyclophosphamide, doxorubicin, and prednisone (R‑CHP) when the member meets International Prognostic Index (IPI) score requirements and relevant molecular features as specified below.

Subsequent treatment: single agent or combined with bendamustine and/or rituximab for relapsed/refractory disease when member is not a transplant candidate or for bridging to CAR T.
First‑line option: Polivy + R‑CHP for members with specified indications and IPI score >1 (DLBCL) or IPI ≥2 for transformation cases and select high‑grade subtypes with required molecular features.

Documentation Required

Required Clinical Documentation

Documentation must support the requested indication, disease subtype, line of therapy, transplant candidacy or use as bridging to CAR T, and International Prognostic Index (IPI) score or other specified molecular features where applicable. Provide clinical records showing prior treatments, response, and rationale for use (including bridging intent) to support medical necessity.

Required documentation: diagnosis subtype, prior lines of therapy, transplant candidacy status or bridging to CAR T rationale, IPI score, relevant molecular/cytogenetic findings (e.g., MYC/BCL6/BCL2 rearrangement status), prior treatment responses, and evidence of absence of unacceptable toxicity.
Use documentation to justify first‑line R‑CHP use with Polivy when IPI and molecular criteria are met.

Denial Risk

Non‑listed Indications

All other indications not listed under the FDA‑approved or compendial uses for B‑cell lymphomas are considered experimental/investigational and not medically necessary.

Non‑listed indications: experimental/investigational — not medically necessary.

Key Definitions

R-CHP (definition and use)

DefinitionR-CHP = rituximab, cyclophosphamide, doxorubicin, and prednisone (given without vincristine) used in combination with Polivy for specified first-line indications

FDA first-line usePolivy + R-CHP is indicated for previously untreated DLBCL (NOS) or HGBL with required IPI thresholds

Transformed disease usePolivy + R-CHP may be used for histologic transformation when IPI threshold is met (e.g., IPI ≥2)

Bridging to CAR T (definition and policy use)

DefinitionBridging therapy = temporary treatment given while awaiting availability of a CAR T-cell product

Policy contextPolivy may be used as a bridging option until a CAR T-cell product is available for members with relapsed/refractory DLBCL, HGBL, PTLD, HIV-related B-cell lymphomas, or transformed disease

Use scenariosAllowed when member is not a candidate for transplant or when CAR T is pending; applies to single-agent Polivy or combination regimens per policy

Background

Polivy (polatuzumab vedotin‑piiq) is addressed in this policy for use in aggressive B‑cell lymphomas. Covered compendial B‑cell lymphoma uses include: high‑grade B‑cell lymphomas (HGBLs); monomorphic post‑transplant lymphoproliferative disorders (B‑cell type); HIV‑related B‑cell lymphomas (for example, HIV‑related DLBCL, primary effusion lymphoma, plasmablastic lymphoma, and HHV8‑positive DLBCL); histologic transformation of indolent lymphomas to DLBCL; histologic transformation to HGBL with MYC and BCL6 without BCL2 rearrangements; and diffuse large B‑cell lymphoma (DLBCL).