Livtencity (maribavir) Drug Quantity Management
Defines drug quantity limits and medical-necessity exceptions for Livtencity (maribavir tablets) for members covered under Cigna-administered health benefit plans.
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).
Coverage Criteria for Livtencity (maribavir)
Drug Quantity Limit and Exceptions
Covered when ALL of the following are met:
Applies unless an exception below is met.
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
| NDC/packaging | Livtencity 200 mg tablets available in bottles of 28 or 56 tablets (per prescribing information). |
Provider Actions, Approvals, and Documentation
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.
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.
- Phenytoin or phenobarbital concomitant use — supports higher exception quantities.
Submission, documentation, and billing guidance
Submit prior authorization requests using the applicable coverage criteria and include clinical documentation that verifies the member meets plan criteria (including age/weight indication when relevant) and any concomitant interacting medications. When billing, use the most appropriate codes for the service and product per benefit requirements.
- Include clinical details demonstrating criteria are met and any interacting anticonvulsant when requesting an exception.
- Use the most appropriate billing codes as of the submission date; claims without covered codes will be denied.
Denial risk for unmet quantity limits or missing exceptions
Coverage may be denied if the Drug Quantity Management rule is not met at point of service or if requests exceed the listed quantity limits and do not meet the specified exceptions; such requests are considered not medically necessary.
- Requests exceeding quantity limits without meeting exception criteria are considered not medically necessary and may be denied.
- If the Drug Quantity Management rule is not met at point of service, coverage will be determined by the criteria below.
Key Definitions
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.
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