CurrentColorado Rocky Mountain Health PlansPolicy 1 = 2026 P 1378-5

Livtencity (maribavir) prior authorization

Prior authorization requirements for Livtencity (maribavir) for treatment of post-transplant CMV infection/disease; applies to prescribers and pharmacy benefit administrators managing member access under this program.

Policy Summary

PayerColorado Rocky Mountain Health Plans

PolicyLivtencity (maribavir) prior authorization

Policy CodePolicy 1 = 2026 P 1378-5

Change TypeAnnual reviewreference updates

Effective Date5/1/2026

Next Review Date

Key ActionObtain prior authorization documenting post-transplant CMV infection/disease refractory to ganciclovir, valganciclovir, cidofovir, or foscarnet; authorization is issued for 2 months.

SourceLink

POLICY UPDATE CHANGES

Annual review; updated background and reference.

Added state mandate language and updated reference.

2 monthsauthorization duration

12+ yrs, ≥35 kgage/weight indicated population

4prior-agent failures listed

5P&T approval years

Coverage Criteria

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Initial Therapy

Covered when ALL of the following are met:

Initial approval conditions: (1) Diagnosis of post-transplant cytomegalovirus (CMV) infection or CMV disease; AND (2) CMV infection or disease is refractory to treatment (with or without genotypic resistance) to one of: ganciclovir, valganciclovir, cidofovir, or foscarnet; AND (3) Patient is not receiving Livtencity in combination with ganciclovir or valganciclovir.

Authorization will be issued for 2 months.

Use of Livtencity (maribavir) in combination with ganciclovir or valganciclovir is not permitted due to documented antagonism between these agents. The manufacturer and policy guidance advise that coadministration may reduce the antiviral activity of ganciclovir and valganciclovir and therefore concomitant use is not recommended.

Provider Actions & Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required. Livtencity (letermovir) will be approved only when the member has a diagnosis of post-transplant CMV infection or CMV disease and documentation shows the CMV is refractory to one of the listed antivirals. Authorization will be issued for up to 2 months. State mandates, federal requirements, and the member's benefit plan may affect coverage.

Affected drug: Livtencity (letermovir)
Authorization duration: up to 2 months

Step Therapy

Step Therapy Requirement

Step requirement — therapy is covered only after failure or refractoriness to one of the following on-label antivirals: ganciclovir, valganciclovir, cidofovir, or foscarnet. Requests must document prior treatment and refractoriness (with or without genotypic resistance) to at least one of these agents.

Required prior agents: ganciclovir; valganciclovir; cidofovir; foscarnet

Documentation Required

Documentation required — include clinical records supporting the diagnosis of post-transplant CMV infection or CMV disease and detailed prior treatment history demonstrating refractoriness to one of the listed antivirals. Indicate whether genotypic resistance testing was performed and results if available.

Documentation: diagnosis, prior antiviral treatment history, evidence of refractoriness, genotypic resistance results (if done)

Denial Risk

Denial triggers — requests that lack documentation that CMV is refractory to ganciclovir, valganciclovir, cidofovir, or foscarnet, or that propose concurrent use of Livtencity with ganciclovir or valganciclovir, will be denied.

Denied if concurrent use with ganciclovir or valganciclovir is requested
Denied if no documentation of refractoriness to at least one listed agent

Note

Additional Clinical Rules

Additional rule: approvals (initial or reauthorization) may be granted based on prior claim/medication history, diagnosis codes (ICD-10), and claim logic consistent with UnitedHealthcare automated processes where applicable.

Approvals may be processed using prior claims/medication history and diagnosis codes

Step	Required prior therapy (must have failed or be refractory to)
1	Ganciclovir
1	Valganciclovir
1	Cidofovir
1	Foscarnet

Definitions

Refractory CMV infection/disease

DefinitionCMV infection/disease that does not respond to treatment with ganciclovir, valganciclovir, cidofovir, or foscarnet (with or without genotypic resistance).

ContextApplies to post-transplant CMV infection or CMV disease in adults and pediatric patients 12 years and older weighing at least 35 kg.

Clinical implicationRefractory status may be documented with lack of clinical response or virologic failure despite therapy with the listed agents.

Treatment restrictionLivtencity should not be coadministered with ganciclovir or valganciclovir due to potential antagonism.