Polivy

Indicated For

relapsed or refractory diffuse large B-cell lymphoma

About This Medication

# POLIVY Access Solutions Patient Guide: How to Get Polivy at Low or No Cost Polivy (polatuzumab vedotin-piiq) is a prescription medicine used to treat adults with relapsed or refractory diffuse large B-cell lymphoma (DLBCL), a type of non-Hodgkin lymphoma, in combination with bendamustine and rituximab, after at least two prior therapies.[1][2] Genentech, the manufacturer, offers **POLIVY Access Solutions**—a comprehensive support program including the **Genentech Oncology Co-pay Assistance Program** for insured patients, referrals to independent foundations, and the **Genentech Patient Foundation** for free medicine if you qualify.[1][3] This guide explains how to access these options in simple terms. It's designed for patients, caregivers, and loved ones facing financial hurdles with Polivy treatment. Always consult your doctor or call POLIVY Access Solutions at **(888) 249-4918** for personalized help.[1] ## Who Qualifies for Assistance? Genentech provides help based on your insurance and finances. Here's a breakdown: - **Commercial Insurance (e.g., employer plans or Marketplace)**: The **Genentech Oncology Co-pay Assistance Program** covers out-of-pocket costs, potentially reducing them to $0 per treatment (up to $25,000 annually). You must have commercial coverage, a valid prescription for an FDA-approved use, and meet other criteria. **Not for government programs like Medicare or Medicaid.**[1][4][9] - **Public Insurance (Medicare, Medicaid) or Commercial with High Costs**: POLIVY Access Solutions refers you to **independent co-pay assistance foundations**—charitable groups that may cover costs.[1] - **No Insurance or Financial Hardship**: The **Genentech Patient Foundation** provides **free Polivy** if you meet income guidelines. Insured patients must first explore other aid; uninsured have separate rules. U.S. residents treated by a U.S.-licensed doctor qualify—no citizenship required.[1][3][6] **Key Note**: Programs have eligibility limits, benefit caps, and can change. Genentech verifies info and may disqualify for inaccuracies.[3][4] ## About Polivy Polivy is an antibody-drug conjugate that targets CD79b on B-cells to deliver chemotherapy directly to cancer cells. It's infused every 21 days in cycles with other drugs for relapsed/refractory DLBCL.[2] Common side effects include low blood counts, fatigue, and neuropathy—discuss risks with your oncologist. POLIVY Access Solutions also helps with **benefits investigations** (checking coverage), **prior authorizations (PA)**, and **appeals** if denied.[2] ## Income Eligibility Breakdown Specific income thresholds aren't publicly listed and vary by program/insurance status. The Genentech Patient Foundation uses federal poverty level (FPL)-based guidelines, applied differently for insured vs. uninsured. Call **(888) 941-3331** or visit GenentechPatientFoundation.com for your quote.[1][6] | Household Size | Estimated Max Income (Uninsured, ~400-500% FPL)* | Estimated Max Income (Insured with Concerns, Lower % FPL)* | Notes | |---------------|---------------------------------------------------|-------------------------------------------------------------|-------| | 1 (Individual) | ~$60,000-$75,000 | ~$30,000-$45,000 | Varies; call for exacts[1][3] | | 2 (Couple) | ~$80,000-$100,000 | ~$40,000-$60,000 | Household income only[6] | | 3 | ~$100,000-$125,000 | ~$50,000-$75,000 | Add ~$20K per person[1] | | 4 | ~$120,000-$150,000 | ~$60,000-$90,000 | Exact via Foundation Specialist | *Estimates based on typical pharma programs; **not official**. Genentech reserves changes.[3] Use their tools for precise eligibility. ## Insurance Requirements - **Commercial Only for Co-pay Program**: Excludes Medicare, Medicaid, VA, etc. May cap if insurer adjusts costs.[4] - **Public/No Insurance**: Foundation or foundations referral.[1] - POLIVY Access Solutions verifies benefits, PA needs, and preferred specialty pharmacies (SPs).[2] Submit **Patient Consent Form** and **Prescriber Service Form** first.[2][5] ## Step-by-Step Application Process 1. **Talk to Your Doctor**: Get a Polivy prescription. Ask them to complete the **Prescriber Service Form** (or Prescriber Foundation Form for free med).[2] 2. **Contact POLIVY Access Solutions**: Call **(888) 249-4918** (English/Spanish/multiple languages, TTY) or **(877) 436-3683** (general, 6am-5pm PT M-F). Request benefits check.[1][2] 3. **Submit Forms**: - **Patient Consent Form**: Online via eSubmit (no hand signature needed), download/fax, or mail.[5] - Prescriber form via My Patient Solutions portal.[2] Both required to start—no extras, or delays occur.[2] 4. **Choose Program**: - Co-pay: Apply at copayassistancenow.com.[9] - Foundation: GenentechPatientFoundation.com or call (888) 941-3331.[1] 5. **Provide Docs**: Income proof (taxes, paystubs), insurance card. Minimal for co-pay.[1] 6. **Specialty Pharmacy**: Your SP handles delivery; program coordinates.[2] ## Timeline and Delivery - **Processing**: Varies; forms submission starts help. Benefits/PA checks quick (days).[2] - **Approval**: Co-pay often immediate if eligible; Foundation may take 1-2 weeks. - **Delivery**: Via SP—home shipment, clinical support. Free med direct to you/doctor.[1][2] Expect 7-14 days total; call for status. ## Alternatives if Denied - **Appeal**: Review denial with plan guidelines. POLIVY specialist/FRM provides sample letters, payer tips.[2] - **Switch Programs**: Try foundations referral or Patient Foundation.[1] - **Other Help**: Patient Access Network (PAN), HealthWell—ask POLIVY team.[1] - **Biosimilars**: None currently available for Polivy.[ ] ## Disclaimer This guide summarizes info as of latest data; programs change. Genentech doesn't guarantee coverage/reimbursement—your/doctor's responsibility. Not medical/financial advice. Verify with POLIVY Access Solutions. Word count: ~950.

Program information last verified: March 25, 2026