MedicaidPrior AuthMedium impact
Prevymis™ (letermovir) (Revised)
Humana·KY, SC, VA · Oncology, Hematology, Nephrology +1 more·Medicaid
Effective date
Mar 25, 2026
We identified it
Jun 25, 2026
Summary
This is a revised Prevymis (letermovir) prior authorization policy effective March 25, 2026, covering CMV prophylaxis in two transplant populations: CMV-seropositive allogeneic HSCT recipients (age ≥6 months, weight ≥6kg, initiated within 28 days post-transplant) and high-risk kidney transplant recipients (D+/R-, age ≥12 years, weight ≥40kg, with documented medical reason for valganciclovir failure). Prior authorization is required for all Prevymis formulations across Kentucky, South Carolina, and Virginia Medicaid programs, with initial and renewal approvals limited to 12 months or clinical review determination.
Action Required
By March 25, 2026: Billing and prior authorization teams must implement the following changes for Kentucky, South Carolina, and Virginia Medicaid plans only: (1) Update prior authorization workflows to require documentation of transplant type and CMV serostatus (R+ for HSCT; D+/R- for kidney transplant); (2) For HSCT recipients, verify transplant occurred within 28 days of Prevymis initiation and confirm age ≥6 months and weight ≥6kg; (3) For kidney transplant recipients, verify age ≥12 years, weight ≥40kg, and documented medical reason for valganciclovir contraindication or failure (e.g., breakthrough infection, adverse effects); (4) Set approval duration limits to 12 months maximum for both initial and renewal requests unless clinical review determines otherwise; (5) Ensure prior auth system captures indication type (HSCT vs. kidney transplant D+/R-) to apply correct criteria; (6) Train front-desk and clinical staff to flag non-compliant requests before submission. Route all Prevymis claims requiring prior authorization through these state-specific Medicaid plans to the review portal at www.humana.com/PAL. Failure to obtain prior authorization or submit incomplete serostatus/transplant documentation will result in claim denials. This policy applies ONLY to Kentucky, South Carolina, and Virginia Medicaid lines of business; do not apply to Medicare Advantage or Traditional Medicare.