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Polivy Patient assistance program

Is your Polivy medication too expensive? Start receiving your medication for only $49 per month.*

Complete a free online enrollment application to find out if you’re eligible to pay only $49 per month for your Polivy medication.

Get started today
  • Secure: Your personal and medical information is safe with us
  • Convenient: We manage the whole process and we’re here to assist you
  • Ongoing refills: We request your medication refills on your behalf
  • Secure: Your personal and medical information is safe with us
  • Convenient: We manage the whole process and we’re here to assist you
  • Ongoing refills: We request your medication refills on your behalf

NiceRx works with your healthcare provider to help you access affordable medications directly from U.S. pharmaceutical companies.

An introduction to NiceRx

Play video (01:52)
  • An introduction to NiceRx
    (01:52)
  • Next steps after qualifying
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  • Uploading documents and billing
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  • SSN & billing information
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  • Medication delivery time
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How it works

  • Apply Online

    Get started by filling out the online enrollment application to find out if you are eligible.

  • Qualification

    NiceRx verifies your eligibility for medication assistance and notifies you if you are qualified.

  • Upload Documents

    You may be required to submit further information and documents required by the pharmaceutical company which can be securely uploaded online.

  • Application Created

    Your application is created and sent to your doctor for signature. At this stage, you will be billed $49 and will not be billed again until you receive your first medication delivery.

  • Receive Medication

    Your application is sent to the pharmaceutical company. You will be billed again once you receive your medication. We handle the entire ordering process including requesting ongoing refills.

Your monthly Polivy cost savings if eligible

With our assistance, you could access the Polivy patient assistance program and obtain your medication for free. We only charge a flat monthly fee of $49 per medication for our services.

Am I eligible for Polivy patient assistance?

We review each Polivy enrollment application individually to determine if you are eligible. Each assistance program has its own eligibility criteria and the factors considered by most programs are:

  • I am a permanent, legal resident of the United States or Puerto Rico
  • I am uninsured or my insurance doesn’t cover my medication
  • I meet certain income eligibility requirements

How do I apply for the Polivy patient assistance program?

Our process makes it as easy as possible to apply for the Polivy patient assistance program. Begin by completing the enrollment application form on our website. Tell us about any medications that you are taking, including Polivy, your healthcare provider, your insurance plan, and your household income. This information is required by the pharmaceutical manufacturers who will supply the medication, so it is important to make sure this information is accurate and up to date.

We will review the information that you have provided to determine whether you are eligible for patient assistance. If we can pre-qualify you for assistance, NiceRx will handle the full enrollment process on your behalf. If you are approved by the pharmaceutical company, you will typically start receiving your medication in 6 – 8 weeks.

Is NiceRx a Polivy coupons provider?

NiceRx is not a Polivy coupon, Polivy discount card, or Polivy copay card provider. We do not offer Polivy manufacturer coupons, Polivy discounts, rebates, Polivy savings cards, trial

offers, or free Polivy samples. We are a service provider that helps eligible individuals access their medication directly from the U.S. pharmaceutical company.

Can NiceRx help me if I have insurance?

NiceRx may be able to help you if:

  • You have a high copay or coinsurance responsibility for Polivy
  • Your insurance company will not pay for your Polivy prescription
  • Your healthcare plan does not cover your medication
  • You do not have insurance

Please apply online to find out if we can help you.

How much does Polivy cost without insurance?

Without insurance, Polivy costs will vary depending on where you buy the medication as prices will vary by retailer. As a guide, Polivy intravenous powder for injection 30 mg will cost around $3,370 for 1 powder for injection.

How much does Polivy cost with insurance?

The copay for Polivy will depend on the terms of your healthcare plan. Your healthcare provider or pharmacist will be able to calculate your copay with your current insurance. Contact them to find out more.

What is Polivy?

Polivy is an FDA (U.S. Food and Drug Administration) approved medication manufactured by Genentech, Inc.

Polivy is a CD79b-directed antibody-drug conjugate used with bendamustine and a rituximab product for the treatment of adult patients with relapsed or refractory diffuse large B-cell lymphoma (DLBCL), not otherwise specified, after at least two prior therapies. Accelerated approval of Polivy was granted for this based on the complete response rate. Continued approval for this may depend upon verification and description of clinical benefit in a confirmatory trial.

What doses of Polivy are available?

Polivy is available in injection form, in the following doses: 140 mg of polatuzumab vedotin-piiq as a lyophilized powder in a single-dose vial.

The recommended dose of Polivy is 1.8 mg/kg, given as an intravenous infusion over 90 minutes, every 21 days for 6 cycles in combination with bendamustine and a rituximab product.

Subsequent infusions may be given over 30 minutes if the previous infusion is tolerated. Give an antihistamine and antipyretic before treatment. See full prescribing information for instructions on preparation and administration. Always speak with a healthcare professional about any changes to your dose so they can monitor and evaluate your condition.

Polivy active ingredients

The active ingredient of Polivy is polatuzumab vedotin, a CD79b antibody-drug conjugate (ADC) with activity against dividing B cancer cells. MMAE is an anti-mitotic agent covalently attached to the antibody via a cleavable linker. The monoclonal antibody binds to CD79b, a B-cell-specific surface protein. After binding CD79b, the polatuzumab vedotin-piiq is internalized, and the linker is cut by lysosomal enzymes to allow intracellular delivery of MMAE. MMAE binds to microtubules and kills dividing cells by blocking cell division and inducing cell death.

The CD79b protein is expressed specifically in the majority of B-cells (an immune cell impacted in some types of non-Hodgkin lymphoma (NHL)), making it a promising target for the development of new therapies. Polivy binds to CD79b and destroys these B-cells through the delivery of an anti-cancer agent, which is thought to minimize the effects on normal cells. Polivy is being developed by Roche, using Seattle Genetics ADC technology, and is currently being tested for the treatment of several types of NHL.

Polivy side effects

The most common side effects of Polivy in clinical trials include:

  • Neutropenia (reduced white blood cells)
  • Thrombocytopenia (reduced platelets)
  • Anemia
  • Fatigue
  • Diarrhea
  • Pyrexia
  • Reduced appetite, weight loss
  • Pneumonia

In rare instances, Polivy can cause more serious adverse reactions. These can include:

  • Peripheral Neuropathy
  • Infusion-related Reactions
  • Myelosuppression – monitor complete blood counts
  • Serious and opportunistic infections
  • Progressive multifocal leukoencephalopathy (PML)
  • Tumor Lysis Syndrome
  • Hepatotoxicity

Your doctor will assess the benefits of using Polivy against your risk of side effects. Patients are encouraged to report negative side effects or adverse reactions of Polivy to the FDA. Visit www.fda.gov/medwatch, or call 1-800-FDA-1088.

Polivy drug interactions

Polivy can interact with other medications. These include:

  • Strong CYP3A inhibitors or inducers

This list is not exhaustive and other prescription drugs may interact with Polivy.

Polivy contraindications

You should not use Polivy if you:

  • Are allergic to the active ingredient polatuzumab vedotin
  • Are allergic to any of the other ingredients in Polivy
  • Are pregnant or are planning to become pregnant – Females of reproductive potential are advised to use effective contraception during treatment and for 3 months after the last dose

Talk to your doctor before using Polivy if you:

  • Are taking any of the medications that could interact with Polivy
  • Are breastfeeding or are planning to breastfeed
  • Have hepatic impairment

Polivy generic

Polivy is the trademark brand name for polatuzumab vedotin manufactured by Genentech, Inc. A generic version of polatuzumab vedotin is not available. Generic drugs are generally cheaper than brand-name drugs, but you can still find Polivy savings through NiceRx.

*Qualifying persons may obtain medications directly from patient assistance programs without any out-of-pocket cost (or for less than $49 per medication). However, our monthly flat rate of just $49 per medication spares you the hassle of tracking down the different programs and filling out all the required paperwork for each program.

Enrollees enjoy a full-service solution, as NiceRx assists them and their physicians with the entire process. We prepare all required documents for the physician to sign, help enrollees manage all prescription refills, monitor eligibility criteria, and maintain enrollment.

**If you do not receive medications because you were determined to be ineligible for the prescription assistance by the applicable pharmaceutical companies and you have a letter of denial, we will refund any fees you paid toward medications for which you did not qualify to receive prescription assistance (“Refund”).

To receive a refund, you must send the letter of denial to us by fax to 888-517-7444, or by e-mail to [email protected] within 30 days of your receipt of such letter. The Refund is your sole and exclusive remedy for any fees you may wish to dispute.

The content on this website is intended for information purposes only. It does not constitute medical advice. The information on this website should not be relied upon and is not a substitute for professional medical advice. You should always speak to your doctor regarding the risks and benefits of any treatment.