CommercialPrior AuthHigh impact
Polatuzumab Vedotin-piiq (Polivy) (CPB 0955, reviewed 2026-09-17)
Aetna·Oncology, Hematology·Medical Policy
We identified it
Sep 30, 2026
Summary
Aetna has established updated coverage criteria for Polatuzumab Vedotin-piiq (Polivy) for treatment of multiple B-cell lymphoma subtypes, including DLBCL, high-grade B-cell lymphomas, and post-transplant lymphoproliferative disorders. All uses require mandatory precertification before administration. Coverage is limited to up to 6 cycles total, with specific combinations and clinical scenarios defined for initial and continuation therapy.
Action Required
IMMEDIATELY: Billing and clinical teams must implement mandatory precertification workflow for all Polivy (J9309) claims. Update billing system to flag J9309 requests requiring prior authorization before claim submission. Establish precertification submission process: call (866) 752-7021 or fax (888) 267-3277 with Statement of Medical Necessity (SMN) forms from Specialty Pharmacy Precertification. Train clinical staff on coverage criteria including: (1) specific B-cell lymphoma subtypes covered; (2) required combination therapies (bendamustine, rituximab, gemcitabine/oxaliplatin, mosunetuzumab-axgb, or R-CHP); (3) clinical scenarios (holding/bridging to CAR-T, relapsed/refractory disease, first-line with IPI >1); (4) 6-cycle maximum per authorization period. Update encounter documentation templates to capture treatment indication, combination regimen, International Prognostic Index score (if applicable), and disease status. Deny and return any J9309 claims submitted without prior authorization approval. Monitor for continuation therapy reauthorization at 6-month mark; reauthorization allowed only if no unacceptable toxicity or disease progression documented.