POLIVY (polatuzumab vedotin-piiq)

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