Livtencity (maribavir) — Medica

Initial criteria

• Patient is ≥ 12 years of age; AND
• Patient weighs ≥ 35 kg; AND
• Patient is post-transplant (hematopoietic stem cell or solid organ transplant); AND
• Patient meets ONE of the following (a or b): a) Cytomegalovirus infection/disease that is refractory to treatment with at least one of the following: cidofovir, foscarnet, ganciclovir, or valganciclovir; OR b) Significant intolerance to ganciclovir or valganciclovir; AND
• Medication is not prescribed in conjunction with ganciclovir or valganciclovir; AND
• Medication is prescribed by or in consultation with a hematologist, infectious diseases specialist, oncologist, or physician affiliated with a transplant center

Reauthorization criteria

• According to the prescriber, patient has responded to Livtencity as demonstrated by cytomegalovirus polymerase chain reaction DNA laboratory results within the past 4 weeks showing improvement in cytomegalovirus levels

Approval duration

2 months