Subject: Specialty Quantity Limit Livtencity 5073-H P2023

Drug

LIVTENCITY  (maribavir)

Policy:

      I.  PROGRAM DESCRIPTION

          The standard limit is designed to allow a quantity sufficient for
          the most common uses of the medication. If the member’s plan
          allows a quantity limit exception review for the requested
          medication, coverage of an additional quantity may be provided
          up to the exception limit with prior authorization.

 
    II.  COVERED QUANTITIES

Medication	Standard Limit	Exception Limit*	FDA-recommended dosing
Livtencity   (maribavir)   200 mg tablets	120 tablets   per 30 days	360 tablets   per 30 days	Take 400 mg orally twice daily   For co-administration with   carbamazepine: Increase   dosage of Livtencity to   800 mg twice daily   For co-administration with   phenytoin or phenobarbital:   Increase dosage of Livtencity   to 1200 mg twice daily

 *Coverage up to the exception limits may be provided with prior authorization via the Specialty Post Limit Quantity
 Exception Criteria for approval.

Place of Service:

Outpatient

The above policy is based on the following references:

1. Livtencity [package insert]. Lexington, MA: Takeda Pharmaceuticals America, Inc.; September 2022.

Copyright Aetna Inc. All rights reserved. Pharmacy Clinical Policy Bulletins are developed by Aetna to assist in administering plan benefits and constitute neither offers of coverage nor medical advice. This Clinical Policy Bulletin contains only a partial, general description of plan or program benefits and does not constitute a contract. Aetna does not provide health care services and, therefore, cannot guarantee any results or outcomes. Participating providers are independent contractors in private practice and are neither employees nor agents of Aetna or its affiliates. Treating providers are solely responsible for medical advice and treatment of members. This Clinical Policy Bulletin may be updated and therefore is subject to change.

June 11, 2023