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(polatuzumab vedotin-piiq) Polivy®

Polatuzumab vedotin-piiq (Polivy) is considered medically necessary for the treatment of adult
patients with diffuse large B-cell lymphoma (DLBCL) when the following criteria are met:

• The patient has relapsed or refractory disease; and

• Polatuzumab vedotin is administered in combination with bendamustine and a rituximab

product; and

• The patient has received at least two prior systemic chemotherapies; and

• The patient is not a candidate for autologous hematopoietic stem cell transplantation (HSCT);

and

• The patient has not previously undergone allogeneic HSCT; and

• The patient does not have active central nervous system lymphoma or histologically

transformed lymphoma.

Authorization: 12 months

Use of polatuzumab vedotin-piiq (Polivy) may be considered medically necessary for clinical

indications not listed above when the drug is prescribed for the treatment of cancer either:

• In accordance with FDA label (when clinical benefit has been established, (see Policy

Guidelines); OR

• In accordance with specific strong endorsement or support by nationally recognized

compendia, when such recommendation is based on strong/high levels of evidence,

and/or uniform consensus of clinical appropriateness has been reached.

787-277-6653 787-474-6326