MedicaidPrior AuthMedium impact
Polivy™ (polatuzumab vedotin-piiq) (Revised)
Humana·FL, KY, SC · Oncology, Hematology·Medicaid
Effective date
Jan 1, 2026
We identified it
Jun 24, 2026
Summary
Humana updated prior authorization requirements for Polivy (polatuzumab vedotin-piiq), a cancer treatment for diffuse large B-cell lymphoma. The policy now covers both relapsed/refractory cases and treatment-naive patients with specific criteria and combination therapy requirements.
Action Required
By January 1, 2026: Oncology teams must ensure prior authorization is obtained for Polivy (polatuzumab vedotin-piiq) prescriptions for Medicaid patients in FL, KY, and SC. Verify patient meets specific criteria including diagnosis confirmation, prior therapy history (for relapsed cases), International Prognostic Index scores (for treatment-naive), and required combination therapies. Document exclusion criteria screening including CNS lymphoma, disease transformation history, and prior stem cell transplant. Update EMR templates to include required clinical documentation for 6-month approval periods.