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Polatuzumab Vedotin-piiq (Polivy) (CPB 0955, reviewed 2025-03-13)
Effective date
Not stated in the notice
Identified
Aug 13, 2026
Summary
Aetna's clinical policy covers polatuzumab vedotin-piiq (Polivy) for commercial medical plans when the criteria for initial approval are met. Those criteria cover HIV-related B-cell lymphomas, diffuse large B-cell lymphoma, high-grade B-cell lymphomas, histologic transformation of indolent lymphomas, B-cell post-transplant lymphoproliferative disorders, mantle cell lymphoma and Burkitt lymphoma, with treatment approved for up to 6 cycles. Aetna considers Polivy experimental, investigational or unproven for all other indications.
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What to do
Action · 7 steps
01Billing team: Polivy requires precertification from Aetna participating providers and members in applicable plan designs.
02Request it by calling (866) 752-7021 or faxing (888) 267-3277, and use the Statement of Medical Necessity precertification forms from the Specialty Pharmacy Precertification page.
03Confirm the requested use matches a listed indication and the treatment setting in the criteria for initial approval before billing HCPCS J9309 (1 mg of polatuzumab vedotin-piiq), which is covered if the selection criteria are met.
04For continuation, Aetna considers therapy medically necessary for up to 6 months (maximum 6 cycles total) when there is no evidence of unacceptable toxicity or disease progression on the current regimen.
05Polivy is listed as 1.8 mg/kg IV over 90 minutes every 21 days for 6 cycles, and subsequent infusions may be given over 30 minutes if the previous infusion was tolerated.
06Premedicate with an antihistamine and antipyretic at least 30 minutes before Polivy.
07Aetna considers Polivy experimental, investigational or unproven for all other indications, so use only the listed indications when billing.
Codes mentioned
J9309382253822638227382289641396415J7512J8530J9000J9033J9034J9036J9056J9071J9072J9073J9074J9075J9076J9184J9196J9198J9201J9263J9286J9311J9312J9350Q2049Q2050Q5115Q5119Q5123C82.00C82.9AC83.00C83.0AC83.10C83.1AC83.30C83.3AC83.70C83.7AC83.80C83.8AC85.10C85.1AC85.20C85.2AC88.40C88.41D47.Z1
Original notice
Polatuzumab Vedotin-piiq (Polivy) (CPB 0955, reviewed 2025-03-13)
aetna.com · Always check the source before changing claims.
Related changes
See all Aetna changes →Polatuzumab Vedotin-piiq (Polivy) (CPB 0955, reviewed 2026-09-17)MediumNo effective date · Medical PolicyObinutuzumab (Gazyva) (CPB 0877, reviewed 2026-06-05)MediumNo effective date · Medical PolicyGlofitamab-gxbm (Columvi) (CPB 1036, reviewed 2026-02-24)MediumNo effective date · Medical PolicyEpcoritamab-bysp (Epkinly) (CPB 1034, reviewed 2026-10-16)MediumNo effective date · Medical PolicyBrowse every Aetna change in the policy list
Related policy hubs
Aetna policiesHematologyOncologyCode J9309Code 38225Code 38226Code 38227Code 38228Code 96413Code 96415Code J7512Code J8530Code J9000Code J9033Code J9034Code J9036Code J9056Code J9071Code J9072Code J9073Code J9074Code J9075Code J9076Code J9184Code J9196Code J9198Code J9201Code J9263Code J9286Code J9311Code J9312Code J9350Code Q2049Code Q2050Code Q5115Code Q5119Code Q5123Code C82.00Code C82.9ACode C83.00Code C83.0ACode C83.10Code C83.1ACode C83.30Code C83.3ACode C83.70Code C83.7ACode C83.80Code C83.8ACode C85.10Code C85.1ACode C85.20Code C85.2ACode C88.40Code C88.41Code D47.Z1