POLIVY (polatuzumab vedotin-piiq)


OFFICE ADMINISTRATION


Indications for Prior Authorization:
  • Indicated in combination with bendamustine and a rituximab product for the treatment of adult patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL) after at least 2 prior therapies.


Patients must meet the following criteria for the indication(s) above:
  • Patient is 18 years of age or older, AND

  • Diagnosis of relapsed or refractory diffuse large B-cell lymphoma or high-grade B-cell lymphoma, AND

  • Prescribed by or in consultation with an oncologist, AND

  • Patient has received at least two prior chemotherapy regimens (e.g. RCHOP, HSCT, CAR T, RCEPP, GemOx), AND

  • Polivy™ will be used in combination with bendamustine and a rituximab product (e.g. Rituxan, Truxima)


Dosing:
  • 1.8 mg/kg IV once every 21 days for 6 cycles (in combination with bendamustine and rituximab)

Approval:
  • 6 months

Last review date: October 15, 2019

Rite Aid Pharmacy Patients: All Rite Aid pharmacies nationwide are closing! Please be on the lookout for information from Rite Aid pharmacies about their bankruptcy and store closures. Call your Rite Aid pharmacy for questions about your prescriptions and new pharmacy options. WHA is here to help as well. Contact Us via Phone