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Limited coverage drugs – letermovir

Last updated on February 13, 2024

Generic name

letermovir

Strength

240 mg, 480 mg

Form

tablet

Special Authority criteria

Approval period

For the prophylaxis of cytomegalovirus (CMV) infection in adult CMV-seropositive recipients [R+] of an allogeneic hematopoietic stem cell transplant (HSCT)

AND

Who are at high risk of CMV infection meeting the following criteria:

  • Umbilical cord blood as stem cell source transplant recipients, OR
  • Haploidentical recipients, OR
  • Recipients of T-cell depleted grafts, OR
  • Recipients of related or unrelated mismatched allogenic stem cell transplant, OR
  • Recipients treated with antithymocyte globulin (ATG) for conditioning, OR
  • Recipients requiring high-dose steroids (defined as the use of ≥ 1 mg/kg/day of prednisone or equivalent dose of another corticosteroid) for acute graft versus host disease (GVHD), OR
  • Recipients treated with ATG for steroid refractory acute GVHD treatment, OR
  • Recipients with documented history of CMV disease prior to transplantation

AND

Patients must have an undetectable CMV DNA at baseline

AND

The treatment is prescribed by a specialist physician with the leukemia/bone marrow transplant program

Maximum coverage is for 100 days per allogeneic HSCT

Practitioner exemptions

  • None

Special notes

  1. PharmaCare coverage of letermovir is limited to one 480 mg or one 240 mg tablet daily
  2. Letermovir should be started after HSCT. Letermovir may be started on the day of transplant and no later than 28 days post-transplant

Special Authority request form(s)