UnitedHealthcare Pharmacy Clinical Pharmacy Programs - Livtencity (maribavir) Prior Authorization/Notification
Defines prior authorization criteria and authorization duration for Livtencity (maribavir) for treatment of post-transplant CMV infection/disease refractory to specified antivirals; includes population, contraindicated coadministration, and program operational notes.
Annual review performed 2/2025 with updated background and reference.
Annual review 2/2024 updated background and reference.
Annual review 2/2023 added state mandate language and updated reference.
Program created (new) in 2/2022.
Coverage Summary
Coverage stance: covered_with_criteria. Scope summary: Defines prior authorization criteria and authorization duration for Livtencity (maribavir) for treatment of post-transplant CMV infection/disease refractory to specified antivirals; includes population, contraindicated coadministration, and program operational notes. Indication: treatment of post-transplant cytomegalovirus (CMV) infection/disease that is refractory to ganciclovir, valganciclovir, cidofovir, or foscarnet. Minimum age: 12 years (and weight ≥35 kg). Note: coadministration with ganciclovir or valganciclovir is not recommended due to antagonism.