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Helpful Resources for Your Practice

POLIVY Access Solutions offers a range of access and reimbursement resources for your patients and practice after POLIVY is prescribed, including help with benefits investigations (BIs), resources for prior authorizations (PAs), sample billing and coding information, resources for denials and appeals, information about distribution and referrals to potential financial assistance options.

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Coverage

Get help understanding insurance benefits and coverage, such as with benefits investigations and prior authorization resources.

Benefits investigations

POLIVY Access Solutions can conduct a benefits investigation (BI) which can determine:

  • If treatment is covered
  • If treatment is denied
  • If a prior authorization or pre-determination is required*
  • If your patient's insurance plan has a mandated or preferred SP

*If your patient’s request for a prior authorization is not granted, your POLIVY Access Solutions Specialist can work with you to determine your next steps.

Option 1: Submit forms online

If your practice has a registered account for My Patient Solutions, you can get started by logging into your account.

Don't have an account?

Your patient is required to complete the Patient Consent Form. You can either upload their Patient Consent Form as part of your application or have your patient submit the form via fax, text or e-submit.

  • An online tool to help you enroll patients in POLIVY Access Solutions and manage your service requests at your convenience.

Option 2: Print forms and fax or text

Step 1: Print one of the Patient Consent Forms below for your patient to complete.

Step 2: Print and complete the Prescriber Service Form below.

Step 3: Submit the completed forms via fax or text.

Both forms are required. We must have both the Patient Consent Form and the Prescriber Service Form before we can help you.

What to expect next:

  • The request will be processed within five business days upon receipt of both required forms.
  • Your office will be contacted to discuss the application outcome and any next steps.

Genentech reserves the right to modify or discontinue the program at any time and to verify the accuracy of information submitted.

The completion and submission of coverage- or reimbursement-related documentation are the responsibility of the patient and healthcare provider. Genentech makes no representation or guarantee concerning coverage or reimbursement for any service or item.


Reimbursement

Sample coding information and resources for denials and appeals

POLIVY Sample Coding

This coding information may assist you as you complete the payer forms for POLIVY. These tables are provided for informational purposes only. Please visit CMS.gov or other payers’ websites to obtain additional guidance on their processes related to billing and coding.

Download sample coding and the important safety information for POLIVY below.

Correct coding is the responsibility of the provider submitting the claim for the item or service. Please check with the payer to verify codes and special billing requirements. Genentech does not make any representation or guarantee concerning reimbursement or coverage for any service or item.

Appeals

If your patient’s health insurance plan has issued a denial, your POLIVY Access Solutions Specialist can provide resources as you prepare an appeal submission, as per your patient’s plan requirements. 

If a plan issues a denial: 

  1. The denial should be reviewed, along with the health insurance plan’s guidelines to determine what to include in your patient’s appeal submission.
  2. Your POLIVY Access Solutions Specialist has local payer coverage expertise and can help you determine specific requirements for your patient.

A sample appeal letter and additional considerations are available on the Practice Forms and Documents page.

Appeals cannot be completed or submitted by Genentech on your behalf.


Online patient enrollment

Submit POLIVY Access Solutions forms and check the status of your service requests online using My Patient Solutions

My Patient Solutions is an online tool to help you enroll patients in POLIVY Access Solutions and manage your service requests, all through one portal. It allows you the flexibility to work with POLIVY Access Solutions when it’s convenient for you.

With My Patient Solutions, you can:

  • Enroll and re-enroll patients in financial assistance programs entirely online

  • Communicate with your POLIVY Access Solutions Specialist

  • Easily identify next steps for service requests
  • 
View Benefits Investigation reports for all your enrolled patients
  • 
Follow up on prior authorizations or appeals
  • View co-pay assistance outcomes and referral information

How to register

Account registration can be completed by one person for the entire practice and for multiple practice locations. For help with registration or if you have questions, call us at 877-GENENTECH (877-436-3683) (6AM-5PM PST, Monday through Friday).


POLIVY Distribution

Genentech has contracted with a network of authorized specialty distributors and specialty pharmacies (SPs) to service practices choosing to prescribe POLIVY.

These partners have made a commitment to product integrity and have agreed to distribute only product purchased directly through Genentech and do not distribute POLIVY through secondary channels.

Authorized Distributors and Specialty Pharmacies

Distributor Telephone Fax Web Orders
ASD Healthcare (a Division of AmerisourceBergen Specialty Group) 800-746-6273
800-547-9413
www.asdhealthcare.com
Cardinal Health Specialty Distribution 800-926-3161 
502-907-3600 (KY)
501-707-2800 (AR)
N/A www.cardinal.com
Dakota Drug 866-210-5887 763-421-0661 www.dakdrug.com/ddos/
DMS Pharmaceutical 877-788-1100 847-518-1105 dmspharma.com/store.htm
McKesson Plasma and Biologics (MPB) 877-625-2566
888-752-7626
connect.mckesson.com
Distributor Telephone Fax Web Orders
ASD Healthcare (a Division of AmerisourceBergen Specialty Group) 800-746-6273 800-547-9413 www.asdhealthcare.com
BioSolutions Direct (a Division of AmerisourceBergen Specialty Group) 866-860-3565 888-899-0063 www.biosolutionsdirect.com
Cardinal Health Specialty Distribution 800-926-3161 888-345-4916 specialtyonline.cardinalhealth.com
CuraScript SD 877-599-7748 800-862-6208 www.curascriptsd.com
McKesson Plasma and Biologics (MPB) 877-625-2566 888-752-7626 connect.mckesson.com
Morris & Dickson Specialty Distribution 800-710-6100 318-524-3096 www.mdspecialtydist.com
Distributor Telephone Fax Web Orders
ASD Healthcare (a Division of AmerisourceBergen Specialty Group) 800-746-6273 800-547-9413 www.asdhealthcare.com
Besse Medical 800-543-2111 800-543-8695 www.besse.com
BioSolutions Direct (a Division of AmerisourceBergen Specialty Group) 866-860-3565 888-899-0063 www.biosolutionsdirect.com
Cardinal Health Specialty Distribution 877-453-3972 614-652-7043
specialtyonline.cardinalhealth.com
CuraScript SD 877-599-7748 800-862-6208
www.curascriptsd.com
McKesson Specialty Health 855-477-9700
800-289-9285 mscs.mckesson.com
Oncology Supply 800-633-7555 800-248-8205 www.oncologysupply.com
Distributor Telephone Fax Web Orders
ASD Healthcare (a Division of AmerisourceBergen Specialty Group) 800-746-6273 800-547-9413 www.asdhealthcare.com
Besse Medical 800-543-2111 800-543-8695 www.besse.com
BioSolutions Direct (a Division of AmerisourceBergen Specialty Group) 866-860-3565 888-899-0063 www.biosolutionsdirect.com
Cardinal Health Specialty Distribution 877-453-3972 614-652-7043
specialtyonline.cardinalhealth.com
CuraScript SD 877-599-7748
800-862-6208
www.curascriptsd.com
McKesson Plasma and
Biologics (MPB)
877-625-2566
888-752-7626
connect.mckesson.com
Distributor Telephone Fax Web Orders
Cardinal Health
Puerto Rico
800-981-4699
787-625-4200
787-625-4398

N/A
Cesar Castillo 787-999-1616
787-720-1095
www.cesarcastillo.net

Please call 888-249-4918 for Specialty Pharmacy distribution for POLIVY.

About Buy and Bill

With Buy and Bill, the practice purchases the medication in advance, then bills the patient's health insurance plan for reimbursement. The practice is responsible for storing and handling the drug as well as collecting the patient's co-pay for both the drug and its administration. With Buy and Bill, practices can maintain a stock of the drug, giving them the flexibility to treat patients when clinically appropriate.

About Specialty Pharmacies

POLIVY Access Solutions works with specialty pharmacies (SPs) to help patients receive their prescribed Genentech medicines.

In addition to distributing medicines, an SP may provide the following services:

  • Reimbursement resources
  • Clinical services to support patients throughout their treatment
  • The ability to manage the specialty handling and shipping needs linked with many specialty therapies

You can work with your preferred SP or contact POLIVY Access Solutions to learn which SP the patient’s health insurance plan mandates or prefers.

Genentech does not influence or advocate the use of any one specialty distributor or specialty pharmacy. We make no representation or guarantee of service or coverage of any item. For any product-specific distribution questions, call POLIVY Access Solutions at 888-249-4918 (6AM-5PM PST, Monday through Friday).


Product issues

We are serious about patient safety. If your Genentech product is spoiled, expired or damaged, we may be able to help you replace it.

Please contact Genentech Customer Service at (800) 551-2231 for any order or return-related questions.

Contact Us

Questions? Contact POLIVY Access Solutions

Call 888-249-4918 (Mon.–Fri., 6AM–5PM PST)

Financial support

Financial Support

Find the right financial resources option for your patients.

Indication

POLIVY in combination with bendamustine and a rituximab product is indicated for the treatment of adult patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL), not otherwise specified, after at least 2 prior therapies.

Accelerated approval was granted for this indication based on complete response rate. Continued approval for this indication may be contingent upon verification and description of clinical benefit in a confirmatory trial.

Peripheral Neuropathy
POLIVY can cause severe peripheral neuropathy. Peripheral neuropathy occurs as early as the first cycle of treatment and is cumulative. POLIVY may exacerbate preexisting peripheral neuropathy.

In Study GO29365, of 173 patients treated with POLIVY, 40% reported new or worsening peripheral neuropathy, with a median time to onset of 2.1 months. The peripheral neuropathy was Grade 1 in 26% of cases, Grade 2 in 12%, and Grade 3 in 2.3%. Peripheral neuropathy resulted in POLIVY dose reduction in 3% of treated patients, dose delay in 1.2%, and permanent discontinuation in 2.9%. Sixty-five percent of patients reported improvement or resolution of peripheral neuropathy, after a median time to resolution of 1 month, and 48% reported complete resolution.

The peripheral neuropathy is predominantly sensory; however, motor and sensorimotor peripheral neuropathy also occur. Monitor for symptoms of peripheral neuropathy such as hypoesthesia, hyperesthesia, paresthesia, dysesthesia, neuropathic pain, burning sensation, weakness, or gait disturbance. Patients experiencing new or worsening peripheral neuropathy may require a delay, dose reduction, or discontinuation of POLIVY.

Infusion-Related Reactions
POLIVY can cause severe infusion reactions. Delayed infusion-related reactions as late as 24 hours after receiving POLIVY have occurred. With premedication, 7% of patients (12/173) in Study GO29365 reported infusion-related reactions after the administration of POLIVY. The reactions were Grade 1 in 67% of patients, Grade 2 in 25%, and Grade 3 in 8%. Symptoms included fever, chills, flushing, dyspnea, hypotension, facial swelling, and urticaria.

Administer an antihistamine and an antipyretic prior to the administration of POLIVY, and monitor patients closely throughout the infusion. If an infusion-related reaction occurs, interrupt the infusion and institute appropriate medical management.

Myelosuppression
Treatment with POLIVY can cause serious or severe myelosuppression, including neutropenia, thrombocytopenia, and anemia. In patients treated with POLIVY plus bendamustine and a rituximab product (BR) (n=45), 42% received primary prophylaxis with granulocyte colony-stimulating factor. Grade 3 or higher hematologic adverse reactions included neutropenia (42%), thrombocytopenia (40%), anemia (24%), lymphopenia (13%), and febrile neutropenia (11%). Grade 4 hematologic adverse reactions included neutropenia (24%), thrombocytopenia (16%), lymphopenia (9%), and febrile neutropenia (4.4%). Cytopenias were the most common reason for treatment discontinuation (18% of all patients).

Monitor complete blood counts throughout treatment. Cytopenias may require a delay, dose reduction, or discontinuation of POLIVY. Consider prophylactic granulocyte colony-stimulating factor administration.

Serious and Opportunistic Infections
Fatal and/or serious infections, including opportunistic infections such as sepsis, pneumonia (including Pneumocystis jiroveci and other fungal pneumonia), herpesvirus infection, and cytomegalovirus infection, have occurred in patients treated with POLIVY.

Grade 3 or higher infections occurred in 32% (55/173) of patients treated with POLIVY. Infection-related deaths were reported in 2.9% of patients within 90 days of last treatment.

Closely monitor patients during treatment for signs of infection. Administer prophylaxis for Pneumocystis jiroveci pneumonia and herpesvirus.

Progressive Multifocal Leukoencephalopathy (PML)
PML has been reported after treatment with POLIVY (0.6%, 1/173). Monitor for new or worsening neurological, cognitive, or behavioral changes. Hold POLIVY and any concomitant chemotherapy if PML is suspected, and permanently discontinue if the diagnosis is confirmed.

Tumor Lysis Syndrome
POLIVY may cause tumor lysis syndrome. Patients with high tumor burden and rapidly proliferating tumors may be at increased risk of tumor lysis syndrome. Monitor closely and take appropriate measures, including tumor lysis syndrome prophylaxis.

Hepatotoxicity
Serious cases of hepatotoxicity that were consistent with hepatocellular injury, including elevations of transaminases and/or bilirubin, have occurred in patients treated with POLIVY.

In recipients of POLIVY in Study GO29365 (n=173), Grade 3 and 4 transaminase elevations of AST and/or ALT developed in 1.9% and 1.9%, respectively. Laboratory values suggestive of drug-induced liver injury (both an ALT or AST greater than 3 times upper limit of normal [ULN] and total bilirubin greater than 2 times ULN) occurred in 2.3% of patients.

Preexisting liver disease, elevated baseline liver enzymes, and concomitant medications may increase the risk of hepatotoxicity. Monitor liver enzymes and bilirubin level.

Embryo-Fetal Toxicity
Based on the mechanism of action and findings from animal studies, POLIVY can cause fetal harm when administered to a pregnant woman. When administered to rats, the small molecule component of POLIVY, monomethyl auristatin E, caused adverse developmental outcomes, including embryo-fetal mortality and structural abnormalities, at exposures below those occurring clinically at the recommended dose.

Advise pregnant women of the potential risk to a fetus. Advise females of reproductive potential to use effective contraception during treatment with POLIVY and for at least 3 months after the last dose. Advise male patients with female partners of reproductive potential to use effective contraception during treatment with POLIVY and for at least 5 months after the last dose.

The Most Common Adverse Reactions
The most common adverse reactions (≥20%) included neutropenia, thrombocytopenia, anemia, peripheral neuropathy, fatigue, diarrhea, pyrexia, decreased appetite, and pneumonia.

Lactation
Advise women not to breastfeed during treatment with POLIVY and for at least 2 months after the last dose.

You may report side effects to the FDA at 1-800-FDA-1088 or www.fda.gov/medwatch. You may also report side effects to Genentech at 1-888-835-2555.

Please see the full Prescribing Information for additional Important Safety Information.

    • POLIVY Prescribing Information. South San Francisco, CA: Genentech, Inc.; September 2020.

      POLIVY Prescribing Information. South San Francisco, CA: Genentech, Inc.; September 2020.

    • Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for B-Cell Lymphomas Update to V.5.2022. © National Comprehensive Cancer Network, Inc. 2022. All rights reserved. Accessed July 28, 2022. To view the most recent and complete version of the guideline, go online to NCCN.org.

      Referenced with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for B-Cell Lymphomas Update to V.5.2022. © National Comprehensive Cancer Network, Inc. 2022. All rights reserved. Accessed July 28, 2022. To view the most recent and complete version of the guideline, go online to NCCN.org.

    • Sehn LH, Herrera AF, Flowers CR, et al. Polatuzumab vedotin in relapsed or refractory diffuse large B-cell lymphoma. J Clin Oncol. 2020;38(2):155-165.

      Sehn LH, Herrera AF, Flowers CR, et al. Polatuzumab vedotin in relapsed or refractory diffuse large B-cell lymphoma. J Clin Oncol. 2020;38(2):155-165.

    • Data on File. South San Francisco, CA: Genentech, Inc. 2018.

      Data on File. South San Francisco, CA: Genentech, Inc. 2018.

    • D’Arena G, Musto P, Cascavilla N, Dell’Olio M, Di Renzo N, Carotenuto M. Quantitative flow cytometry for the differential diagnosis of leukemic B-cell chronic lymphoproliferative disorders. Am J Hematol. 2000;64(4):275-281.

      D’Arena G, Musto P, Cascavilla N, Dell’Olio M, Di Renzo N, Carotenuto M. Quantitative flow cytometry for the differential diagnosis of leukemic B-cell chronic lymphoproliferative disorders. Am J Hematol. 2000;64(4):275-281.

    • Dornan D, Bennett F, Chen Y, et al. Therapeutic potential of an anti-CD79b antibody-drug conjugate, anti-CD79b-vc-MMAE, for the treatment of non-Hodgkin lymphoma. Blood. 2009;114(13):2721-2729.

      Dornan D, Bennett F, Chen Y, et al. Therapeutic potential of an anti-CD79b antibody-drug conjugate, anti-CD79b-vc-MMAE, for the treatment of non-Hodgkin lymphoma. Blood. 2009;114(13):2721-2729.

    • Friedberg JW. Relapsed/refractory diffuse large B-cell lymphoma. Hematology Am Soc Hematol Educ Program. 2011;2011(1):498-505.

      Friedberg JW. Relapsed/refractory diffuse large B-cell lymphoma. Hematology Am Soc Hematol Educ Program. 2011;2011(1):498-505.

    • Crump M, Neelapu SS, Farooq U, et al. Outcomes in refractory diffuse large B-cell lymphoma: results from the international SCHOLAR-1 study. Blood. 2017;130(16):1800-1808.

      Crump M, Neelapu SS, Farooq U, et al. Outcomes in refractory diffuse large B-cell lymphoma: results from the international SCHOLAR-1 study. Blood. 2017;130(16):1800-1808.

    • National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE) V4. 2009.
      https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf. Accessed December 4, 2019.

      National Cancer Institute. Common Terminology Criteria for Adverse Events (CTCAE) V4. 2009.
      https://evs.nci.nih.gov/ftp1/CTCAE/CTCAE_4.03/CTCAE_4.03_2010-06-14_QuickReference_5x7.pdf. Accessed December 4, 2019.