CurrentCignaPolicy N/A

Livtencity (maribavir) Drug Quantity Management Policy - Per Days

Defines drug quantity limits and authorization criteria for Livtencity (maribavir tablets) for Cigna-administered health benefit plans, including retail and home delivery dispensing limits and adjustments when given with enzyme-inducing anticonvulsants.

Policy Summary

PayerCigna

PolicyLivtencity (maribavir) Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionApprove up to 8 weeks' supply when quantity limits or documented interaction-based override criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

112Retail max per 28 days (standard)

224Home delivery max per 56 days (standard)

224Retail max w/ carbamazepine per 28 days

336Retail max w/ phenytoin or phenobarbital per 28 days

8 weeksAuthorization duration

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Coverage Criteria

Drug Quantity Limit and Interaction-Based Overrides

Covered as medically necessary when quantity limits or documented interaction-based override criteria are met. All approvals are for up to 8 weeks unless otherwise noted.

Standard quantity limits: Standard maximum quantities: Retail = 112 tablets per 28 days; Home Delivery = 224 tablets per 56 days.

Standard supply equals two 200 mg tablets twice daily (400 mg BID)

Override for carbamazepine coadministration: If patient is taking carbamazepine concomitantly with Livtencity, approve 224 tablets per 28 days for up to 8 weeks (56 days) at retail or a one-time override for 448 tablets as a 56-day supply at home delivery.

Reflects dose increase when coadministered with carbamazepine; approvals limited to up to 8 weeks.

Override for phenytoin or phenobarbital coadministration: If patient is taking phenytoin or phenobarbital concomitantly with Livtencity, approve 336 tablets per 28 days for up to 8 weeks (56 days) at retail or a one-time override for 672 tablets as a 56-day supply at home delivery.

Reflects dose increase when coadministered with phenytoin or phenobarbital; approvals limited to up to 8 weeks.

Any requests for quantities of Livtencity (maribavir) that exceed the specified maximums and do not meet the interaction‑based override criteria are considered not medically necessary.

Any exception to the stated product quantity limits for Livtencity (maribavir) that does not satisfy the published criteria (including interaction‑based overrides) is considered not medically necessary.

Provider Actions and Requirements

Prior Authorization

Authorization duration and exception rule

All approvals for Livtencity are provided for up to 8 weeks (56 days). Exceptions to the standard quantity limits (for patients taking carbamazepine, phenytoin, or phenobarbital) must meet the specific interaction-based criteria described in the policy in order to qualify for the increased quantities or one-time home delivery overrides.

Standard approvals: up to 8 weeks unless otherwise noted.
Exceptions (interaction-based overrides) require meeting the criteria for coadministration with carbamazepine, phenytoin, or phenobarbital.

Step Therapy

Step therapy

This quantity management policy does not impose any step therapy requirements for Livtencity.

Background

Livtencity (maribavir) is an antiviral provided as 200 mg tablets. Standard quantity limits are 112 tablets per 28 days (retail) or 224 tablets per 56 days (home delivery), which corresponds to the recommended two 200 mg tablets twice daily dosing used in clinical studies for up to 8 weeks in post‑transplant CMV refractory disease.

Definitions

Definition: post-transplant CMV infection/disease refractory to treatment

TermPost-transplant cytomegalovirus (CMV) infection/disease refractory to treatment

DefinitionCMV infection/disease occurring after transplantation that is refractory to treatment with ganciclovir, valganciclovir, cidofovir, or foscarnet.

Applicable populationAdults and pediatric patients ≥12 years and ≥35 kg as indicated in the prescribing information.

Definition: carbamazepine, phenytoin, phenobarbital coadministration

Interacting agentsCarbamazepine, phenytoin, phenobarbital

Clinical implicationThese anticonvulsants are enzyme inducers that require Livtencity dose increases when coadministered.

Quantity Limits and Overrides

Standard retail quantity limit

DrugLivtencity (maribavir) 200 mg tablets

Retail maximum quantity per 28 days (standard)112 tablets

Standard supply rationaleAllows two 200 mg tablets twice daily (400 mg BID) for 28 days.

Standard home delivery quantity limit

DrugLivtencity (maribavir) 200 mg tablets

Home delivery maximum quantity per 56 days (standard)224 tablets

Standard supply rationale

Policy Summary

PayerCigna

PolicyLivtencity (maribavir) Drug Quantity Management Policy - Per Days

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionApprove up to 8 weeks' supply when quantity limits or documented interaction-based override criteria are met.

SourceLink

On This Page

Documentation Required

Documentation and review context

Coverage determinations must consider the terms of the applicable benefit plan, any applicable laws/regulations, relevant collateral materials including coverage policies, and the specific facts of the situation; Medical Directors retain clinical judgment and discretion in individual determinations.

Review the applicable benefit plan document in effect on the date of service.
Consider applicable laws/regulations and relevant collateral materials (including coverage policies).
Documented clinical facts may be reviewed by Medical Directors exercising discretion.

Denial Risk

Quantity management enforcement

If the Drug Quantity Management rule is not met at the point of service, coverage will be determined by the policy criteria; any quantity requests exceeding the specified maximums that do not meet the interaction-based override criteria are considered not medically necessary.

Standard maximums: Retail 112 tablets per 28 days; Home delivery 224 tablets per 56 days.
Interaction-based overrides (carbamazepine, phenytoin, phenobarbital) must be documented to qualify for higher quantities.

Dose adjustments statedIncrease Livtencity to 800 mg BID with carbamazepine; to 1,200 mg BID with phenytoin or phenobarbital.

Equivalent to two 200 mg tablets twice daily for 56 days (one home-delivery supply).

Retail override when coadministered with carbamazepine

InteractionCoadministration with carbamazepine

Retail override quantity per 28 days224 tablets

Authorization durationApprove for up to 8 weeks (56 days) at retail when criteria met.

Retail override when coadministered with phenytoin or phenobarbital

InteractionCoadministration with phenytoin or phenobarbital

Retail override quantity per 28 days336 tablets

Authorization durationApprove for up to 8 weeks (56 days) at retail when criteria met.

Home delivery override for carbamazepine coadministration

InteractionCarbamazepine coadministration (home delivery)

Home delivery override quantity per 56 days448 tablets

NotesOne-time override as a 56-day supply when criteria are met.

Home delivery override for phenytoin or phenobarbital coadministration

InteractionPhenytoin or phenobarbital coadministration (home delivery)

Home delivery override quantity per 56 days672 tablets

NotesOne-time override as a 56-day supply when criteria are met.