CurrentCignaPolicy N/A

Livtencity (maribavir) Drug Quantity Management

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Defines drug quantity limits and medical-necessity exceptions for Livtencity (maribavir tablets) for members covered under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyLivtencity (maribavir) Drug Quantity Management

Policy CodePolicy N/A

Change TypeRevised quantity limits and approval duration

Effective DateN/A

Last ReviewNov 12, 2025

Next Review DateNov 12, 2025

Key ActionSubmit prior authorization requests documenting concomitant anticonvulsant use when requesting expanded quantity limits.

SourceLink

POLICY UPDATE CHANGES

Policy statement was modified to 'All approvals are provided for 1 year, unless otherwise noted below.' Previously, All approvals are provided for 8 weeks, unless otherwise noted below.

Livtencity 200 mg tablet home delivery quantity limit changed from 224 tablets per 56 days to 336 tablets per 84 days.

Override criteria updated to allow 224 tablets per 28 days retail or 672 per 84 days home delivery when coadministered with carbamazepine (previously limited to up to 8 weeks/one-time overrides).

Override criteria updated to allow 336 tablets per 28 days retail or 1,008 per 84 days home delivery when coadministered with phenytoin or phenobarbital (previously limited to up to 8 weeks/one-time overrides).

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CurrentCignaPolicy N/A

Livtencity (maribavir) Drug Quantity Management

Customize your policy alerts

Sign up for all Cigna policy alerts

Know when Cigna releases new policies or updates existing guidance.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Defines drug quantity limits and medical-necessity exceptions for Livtencity (maribavir tablets) for members covered under Cigna-administered health benefit plans.

Policy Summary

PayerCigna

PolicyLivtencity (maribavir) Drug Quantity Management

Policy CodePolicy N/A

Change TypeRevised quantity limits and approval duration

Effective DateN/A

Last ReviewNov 12, 2025

Next Review DateNov 12, 2025

Key ActionSubmit prior authorization requests documenting concomitant anticonvulsant use when requesting expanded quantity limits.

SourceLink

POLICY UPDATE CHANGES

Policy statement was modified to 'All approvals are provided for 1 year, unless otherwise noted below.' Previously, All approvals are provided for 8 weeks, unless otherwise noted below.

Livtencity 200 mg tablet home delivery quantity limit changed from 224 tablets per 56 days to 336 tablets per 84 days.

Override criteria updated to allow 224 tablets per 28 days retail or 672 per 84 days home delivery when coadministered with carbamazepine (previously limited to up to 8 weeks/one-time overrides).

Coverage Criteria for Livtencity (maribavir)

Drug Quantity Limit and Exceptions

Covered when ALL of the following are met:

Default quantity limits: For Livtencity 200 mg tablets, approve up to 112 tablets per 28 days (retail) or 336 tablets per 84 days (home delivery).112/28 days retail; 336/84 days home delivery

Applies unless an exception below is met.

Exceptions for interacting anticonvulsants: If patient is taking carbamazepine concomitantly, approve 224 tablets per 28 days retail or 672 tablets per 84 days home delivery; if taking phenytoin or phenobarbital concomitantly, approve 336 tablets per 28 days retail or 1,008 tablets per 84 days home delivery.see text

These are the covered exceptions; any other exception is considered not medically necessary.

Exceptions to the default quantity limits are limited to specified concomitant use with certain anticonvulsants. Specifically, if the member is taking carbamazepine concomitantly with Livtencity, approve up to 224 tablets per 28 days (retail) or 672 tablets per 84 days (home delivery). If the member is taking phenytoin or phenobarbital concomitantly with Livtencity, approve up to 336 tablets per 28 days (retail) or 1,008 tablets per 84 days (home delivery). All other exceptions to the listed quantity limits are not covered.

Requests that exceed the specified quantity limits when the above exception criteria are not met are considered not medically necessary and may be denied. Only the concomitant use with carbamazepine, phenytoin, or phenobarbital constitutes an allowable exception to the stated retail and home delivery quantity limits.

Product Coding and Indication

Product availabilitymixed

NDC/packaging

Livtencity 200 mg tablets available in bottles of 28 or 56 tablets (per prescribing information).

Age / Weight Eligibility

Age indicationPatients aged ≥ 12 years

Weight indicationPatients weighing ≥ 35 kg

Combined age/weight eligibility (most actionable)Indicated for patients ≥ 12 years and ≥ 35 kg

Provider Actions, Approvals, and Documentation

Prior Authorization

Quantity limits and approval duration

All approvals for Livtencity (maribavir) are provided for 1 year unless otherwise noted. The default quantity limits are 112 tablets per 28 days for retail and 336 tablets per 84 days for home delivery; specified exceptions for interacting anticonvulsants permit higher quantities (see exception callouts).

Approval duration: 1 year (unless otherwise noted).
Retail quantity limit: 112 tablets per 28 days.
Home delivery quantity limit: 336 tablets per 84 days.

Note

Document concomitant interacting anticonvulsant

If the patient is taking an interacting anticonvulsant, document the specific concomitant medication to support the exception: carbamazepine (allows increased retail/home quantities) or phenytoin/phenobarbital (allows higher increased retail/home quantities).

Carbamazepine concomitant use — supports exception quantities.

Key Definitions

Refractory CMV

Definition of Refractory CMV (concise)Persistent signs or symptoms of CMV disease or persistent CMV DNAemia despite treatment

Clinical implicationMay require continued treatment beyond trial durations (e.g., beyond 8 weeks) until CMV DNAemia resolves

MonitoringCMV viral load should be monitored (often weekly) to assess response and identify persistent DNAemia

Resistant CMV

Definition of Resistant CMV (concise)Detection of known viral genetic mutation(s) that decrease susceptibility to one or more anti‑CMV medications

Clinical implicationGenotypic resistance may necessitate alternative antiviral therapy or dosing adjustments

Clinical Background

Livtencity (maribavir) is supplied as 200 mg tablets and is indicated for treatment of post-transplant cytomegalovirus (CMV) infection/disease refractory to or resistant to available anti‑CMV therapies. The policy establishes default quantity limits of 112 tablets per 28 days (retail) or 336 tablets per 84 days (home delivery), with increased allowances only when specific interacting anticonvulsants are used concomitantly as described above. Prescribers should account for increased dosing recommendations when Livtencity is coadministered with carbamazepine, phenytoin, or phenobarbital and request quantities consistent with those approved exceptions.