Prevymis (letermovir) — United Healthcare

Initial criteria

• EITHER of the following:
• 1) ALL of the following:
• - Patient is a recipient of an allogeneic hematopoietic stem cell transplant
• - AND - Patient is CMV-seropositive
• - AND - Provider attests that Prevymis will be initiated between Day 0 and Day 28 post-transplantation (before or after engraftment) and is prescribed as prophylaxis and not treatment of CMV infection
• OR
• 2) ALL of the following:
• - Patient is a recipient of a kidney transplant
• - AND - Patient is CMV-seronegative
• - AND - Donor is CMV-seropositive
• - AND - Provider attests that Prevymis will be initiated between Day 0 and Day 7 post-transplantation (before or after engraftment) and is prescribed as prophylaxis and not treatment of CMV infection

Reauthorization criteria

• All requests for reauthorization will be denied; continuation requests must be submitted through the appeals process to UnitedHealthcare Pharmacy appeals for consideration.

Approval duration

9 months