Prevymis (letermovir tablets, oral pellets) — CareFirst (Caremark)

Initial criteria

• For CMV prophylaxis in hematopoietic stem cell transplant recipients: patient is an adult or pediatric patient age ≥ 6 months and weighing ≥ 6 kg who is CMV-seropositive [R+] and a recipient of an allogeneic hematopoietic stem cell transplant, AND there is a valid medical reason why the patient requires treatment beyond the recommended duration post transplantation.
• For CMV prophylaxis in kidney transplant recipients: patient is an adult or pediatric patient age ≥ 12 years and weighing ≥ 40 kg who is a kidney transplant recipient at high risk (Donor CMV seropositive/Recipient CMV seronegative [D+/R–]), AND there is a valid medical reason why the patient requires treatment beyond the recommended duration post transplantation.

Approval duration

4 months