Limited coverage criteria – maribavir

Generic name

Strength & form

200mg oral film-coated tablet

Initial

For the treatment of patients aged 18 years or older with post-hematopoietic cell transplant cytomegalovirus (CMV) infection or disease who are refractory to one or more prior antiviral therapies meeting either of the following criteria:

• CMV viral load has plateaued or increased after a minimum of 21 days of treatment with any of the following medications:
  • ganciclovir
  • valganciclovir
  • foscarnet
  • cidofovir

OR

• Documentation of 1 or more CMV genetic mutations associated with resistance to ganciclovir or valganciclovir

AND meeting ALL of the following conditions:

• CMV baseline viral load level was above 1000 IU/mL and required treatment, and
• Coverage is requested by a transplant infectious disease (ID) specialist physician

8 weeks

Renewal

For the continued treatment of adult patients with post-hematopoietic cell transplant CMV infection or disease who meet the following conditions:

• Patient has persistent viremia with CMV viral load above 200 IU/mL after 8 weeks of treatment with maribavir

AND

• Coverage renewal is prescribed requested by a transplant ID specialist physician