Polivy (polatuzumab vedotin-piiq) — HCPCS J9309

CareCost Estimate · Billing Cheat Sheet

Genentech (Roche) 30 mg lyophilized single-dose vial 1.8 mg/kg IV q21d × 6 cycles (always combo) Reviewed: May 2, 2026 ASP: Q4 2026

HCPCS

J9309

1 mg = 1 unit

Dose

1.8 mg/kg

75 kg = 135 units

Modifier

Weight-based waste (frequent)

Admin CPT

96413

+96415 for cycle 1 only if documented at 91+ min

Medicare ASP+6%

$144.103

/mg · $19,453.91/135 mg

Codes & NDC

HCPCS	`J9309` — "Inj, polatuzumab vedotin, 1 mg" (permanent, eff. 1/1/2020)
NDC	`50242-104-01` (10) / `50242-0104-01` (11) — N4 qualifier
Vial	30 mg lyophilized single-dose — reconstitute 7.2 mL SWFI → 20 mg/mL
Storage	Refrig 2–8°C; reconstituted ≤8 hr refrig / ≤4 hr RT; do not freeze, swirl don't shake
Benefit	Medical (provider buy-and-bill); not specialty pharmacy

POLARIX R-CHP regimen (1L DLBCL, IPI ≥2)

Drug	Dose	Day	Cycles
Polivy	1.8 mg/kg IV	D1	1–6
Rituximab	375 mg/m² IV	D1	1–8
Cyclophosphamide	750 mg/m² IV	D1	1–6
Doxorubicin	50 mg/m² IV	D1	1–6
Prednisone	100 mg PO	D1–5	1–6
Vincristine	OMITTED — Polivy replaces it (avoids neurotoxic overlap)

R/R DLBCL: Polivy + bendamustine 90 mg/m² D1–2 + rituximab 375 mg/m² D1, q21d × 6 (after ≥2 prior systemic).

JW waste table (1.8 mg/kg, 30 mg vials)

Wt	Dose	Vials	Waste	Mod
50 kg	90 mg	3	0	JZ
60 kg	108 mg	4	12	JW
70 kg	126 mg	5	24	JW
75 kg	135 mg	5	15	JW
80 kg	144 mg	5	6	JW
90 kg	162 mg	6	18	JW
100 kg	180 mg	6	0	JZ

JW required on most claims. Only 30 mg vial size; weight-based dosing produces partial-vial waste at most weights. Bill administered units on one line + waste on JW line.

Administration

Code	When
`96413`	Chemo IV initial — every cycle
`96415`	Each addl hr — cycle 1 only only if documented at 91+ min
`96417`	Sequential infusions — for other R-CHP backbone drugs
`96365`	NOT appropriate — Polivy is ADC w/ cytotoxic payload

ICD-10 — DLBCL

Code	For
`C83.30`	DLBCL, unspecified site (most common)
`C83.31–C83.39`	DLBCL by site (head/neck, intrathoracic, abdominal, axilla, inguinal, pelvic, spleen, multiple, extranodal)
`C85.20`	PMBCL — off-label for Polivy
`C85.9x`	NHL unspecified — insufficient; need DLBCL pathology

DLBCL landscape comparison

Drug	HCPCS	Class	Line
Polivy	J9309	CD79b ADC	1L (POLARIX) + 3L+
Rituxan	J9312	Anti-CD20 mAb	1L backbone
Columvi	J9286	CD20×CD3 bispecific	R/R 3L+ (mono)
Epkinly	J9321	CD20×CD3 bispecific (SC)	R/R 3L+ (mono)
Lunsumio	J9350	CD20×CD3 bispecific	R/R follicular 3L+

Polivy is the only ADC for DLBCL combo regimens. Bispecifics are monotherapy with step-up dosing.

Payer requirements (May 2026)

Payer	PA	Key criteria
UnitedHealthcare	Yes	DLBCL pathology + IPI ≥2 (1L) or ≥2 prior systemic (R/R); concurrent PA on combo
Aetna	Yes	FDA-labeled only; NCCN-aligned; IPI ≥2 documented
BCBS plans	Yes	NCCN B-cell lymphoma + FDA label aligned
Medicare LCDs	No (FFS); MA yes	FDA-labeled indications

Concurrent PA required on Rituxan + cyclophosphamide + doxorubicin (R-CHP) or bendamustine + Rituxan (BR). Approving Polivy alone is insufficient.

Medicare reimbursement (Q4 2026)

Field	Value
ASP + 6%	$144.103 / mg (eff. 7/1 – 9/30/2026)
135 mg dose (75 kg)	$19,453.91
162 mg dose (90 kg)	$23,344.69
POLARIX 6-cycle total (75 kg)	~$111,154 Polivy alone

Site of care

Setting	POS	Notes
Comprehensive cancer ctr HOPD	22	Common for POLARIX
HOPD (off-campus PBD)	19	Common
Physician oncology office	11	OK w/ chemo infrastructure
Ambulatory infusion suite	49	OK w/ multi-drug capability
Inpatient (cycle 1 high-risk)	21	Sometimes

Patient assistance — Genentech

Phone: 1-866-422-2377 (Genentech Access Solutions, M–F 6 AM–5 PM PT)
Commercial copay: $0 up to $25,000/year (Oncology Co-pay Card)
Patient Foundation: free product for uninsured/underinsured
Foundations (Medicare): PAN, HealthWell, CancerCare, LLS Co-Pay
Web: genentech-access.com/hcp/brands/polivy.html

PERIPHERAL NEUROPATHY — ~64% incidence, dose-limiting. MMAE payload causes sensory/motor neuropathy that may be cumulative and persist after discontinuation. Assess at each dose. Grade 2: withhold & resume at 1.4 mg/kg. Grade 3+: permanently discontinue. POLARIX replaces vincristine in R-CHOP precisely to avoid neurotoxic overlap.

NO Boxed Warning, but W&P include: infusion reactions, myelosuppression (G-CSF often added), serious infections (PJP/HSV/VZV prophylaxis), PML (rare), tumor lysis syndrome, hepatotoxicity, embryo-fetal toxicity.

Sources: FDA Polivy PI (April 2023 POLARIX 1L), Tilly et al. NEJM 2022 (POLARIX), CMS ASP Q4 2026, NCCN B-cell lymphoma, Genentech Access Solutions, UHC/Aetna oncology policies. carecostestimate.com/drugs/polivy