Limited coverage criteria – letermovir

letermovir

240 mg, 480 mg tablet

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 and a Special Authority request is submitted by a specialist physician with the leukemia/bone marrow transplant program

Maximum coverage is for 100 days per allogeneic HSCT