Polivy

Indicated For

Relapsed or refractory diffuse large B-cell lymphoma (DLBCL)

About This Medication

# Genentech Patient Foundation Patient Guide: How to Get Polivy (polatuzumab vedotin-piiq) at Low or No Cost Polivy (polatuzumab vedotin-piiq) is a prescription medicine used in combination with other drugs to treat adults with relapsed or refractory diffuse large B-cell lymphoma (DLBCL), a type of non-Hodgkin lymphoma, after at least two prior therapies.[1][4][7] The **Genentech Patient Foundation** offers **free Polivy** to eligible patients who are uninsured, lack coverage for the medicine, or meet specific income criteria after trying other assistance options.[1][2][4] ## About Polivy **Polivy** is an antibody-drug conjugate that targets cancer cells expressing CD79b, delivering a chemotherapy agent directly to lymphoma cells while sparing healthy ones.[7] It is administered intravenously in a clinical setting, typically every three weeks as part of the Polivy + BR regimen (Polivy with bendamustine and rituximab). Common side effects include low blood cell counts, fatigue, diarrhea, and infusion reactions—discuss risks with your doctor.[7] Always take Polivy as prescribed for FDA-approved uses only.[4] ## Who Qualifies? Eligibility focuses on financial need and insurance status, not U.S. residency alone (though programs prioritize U.S. patients).[1][4] Key groups: - **Uninsured patients** or those without coverage for Polivy. - **Insured patients** who have tried other assistance (e.g., co-pay programs) but still face high costs, meeting income limits. - Exclusions: Patients with federal/state government-reimbursed prescriptions (e.g., Medicare Part A/B in certain cases—check specifics).[4][9] **Income Eligibility Breakdown** Specific thresholds aren't publicly fixed; they vary by category and are assessed case-by-case. Insured patients with coverage must exhaust other options first and meet stricter limits; uninsured/underinsured have broader criteria.[1][4] Contact (888) 941-3331 for your situation.[2][9] | Household Size | Uninsured/ No Coverage for Polivy | Insured with Coverage (After Other Assistance) | Notes | |---------------|----------------------------------|-----------------------------------------------|-------| | Individual | Contact for criteria | Stricter limits; pursue other help first | Varies; FPL-based[1][4] | | Couple | Contact for criteria | Stricter limits; pursue other help first | Call to confirm[2] | | Family of 3 | Contact for criteria | Stricter limits; pursue other help first | Genentech verifies[4] | | Family of 4+ | Contact for criteria | Stricter limits; pursue other help first | Right to verify info[1] | Call Foundation Specialists at (888) 941-3331 (Mon-Fri, 6 a.m.–5 p.m. PT) for exact thresholds—they provide personalized guidance.[9] ## Insurance Requirements - **Eligible**: Uninsured; insured without Polivy coverage; insured who tried other assistance but need help.[4][7] - **Not Eligible**: Government-reimbursed prescriptions; must use FDA-approved indications.[4] - Medicare patients: May qualify if no coverage or after appeals/other options; proof of appeal not required but appeals can run parallel.[9] POLIVY Access Solutions can check coverage, prior authorizations, or appeals first.[7] ## Step-by-Step Application Process Applications are free and use **multiple methods** (online, fax, text).[2][7] Both forms are **required**—no action until received.[1][2] 1. **Discuss with your doctor**: Confirm Polivy prescription and eligibility. Doctor completes **Prescriber Foundation Form**.[1][2] 2. **Complete Patient Consent Form**: Sign (English/Spanish available). Available at genentech-access.com or gene.com/patients.[2] 3. **Submit together**: - **Online (fastest)**: Patient does Consent Form; doctor does Prescriber Form via My Patient Solutions or eSubmit.[1][2] - **Print/Fax**: Fax both to 833-999-4363.[2] - **Text**: Photo of signed forms to 650-877-1111.[2] - Visit https://www.genentech-access.com or call (888) 941-3331.[1] 4. **Processing**: Within **5 business days**; office contacted with outcome.[2][6] **Tip**: Download forms from Genentech sites; Spanish versions available. No extra docs needed—extras delay processing.[7][9] ## Timeline and Delivery - **Approval**: 5 business days after both forms received.[2][6] - **Reauthorization**: **Required**—reauth every 12 months or per treatment cycle; resubmit forms.[8] - **Delivery**: Free Polivy shipped to your home, doctor's office, or participating pharmacy.[Program Details] - One year of medicine typically provided upon approval.[8] ## Alternatives if Denied - **Appeal insurance denial**: Use POLIVY Access Solutions for prior auth/appeal help; resources include sample letters, FDA approval info.[1][7] - **Co-pay programs**: For commercial/public insurance, get referrals to independent foundations via POLIVY Access Solutions.[4] - **Other options**: Specialty pharmacies, state programs, or Genentech Field Reimbursement Manager.[7] - **Reapply**: Fix issues (e.g., missing forms) and resubmit; call for guidance.[9] - No biosimilars available.[Program Details] ## Important Disclaimer This guide is for informational purposes based on available program details as of 2026.[8] Eligibility, benefits, and terms can change; Genentech reserves rights to modify/discontinue.[4] Not a guarantee of approval—contact (888) 941-3331 for latest info. Consult your doctor; Genentech doesn't guarantee coverage/reimbursement.[7] Download brochure at gene.com/patients/patient-foundation.[3] (Word count: 942)

Program information last verified: March 30, 2026