MedicaidPrior AuthMedium impact
Prevymis™ (letermovir) (Revised)
Humana·KY, SC, VA · Oncology, Hematology, Transplant Surgery +1 more·Medicaid
Effective date
Jul 22, 2026
We identified it
Jul 23, 2026
Summary
This is a revised Prevymis (letermovir) prior authorization policy for Medicaid in Kentucky, South Carolina, and Virginia. The policy clarifies coverage for CMV prophylaxis in allogeneic hematopoietic stem cell transplant (HSCT) recipients (R+) and for CMV prophylaxis/treatment in solid organ transplant recipients who cannot tolerate valganciclovir. All requests require prior authorization with specific clinical criteria, age/weight requirements, and approval durations up to 12 months.
Action Required
By July 22, 2026: Billing team must implement prior authorization requirements for Prevymis (letermovir) in the billing system for all Medicaid claims in Kentucky, South Carolina, and Virginia. Add authorization logic to flag claims for: (1) HSCT recipients age ≥6 months, weight ≥6kg, CMV-seropositive, initiated within 28 days post-transplant; (2) Solid organ transplant recipients age ≥12 years, weight ≥40kg with documented medical reason for valganciclovir failure/intolerance. Update prior auth request templates to capture transplant type, CMV serology status, transplant date, and clinical justification. Train billing and clinical staff on new approval duration (up to 12 months initial and renewal). Notify providers that Prevymis injection requires documented inability to take oral therapy with plan to switch to oral formulation. All claims submitted without prior authorization or failing to meet clinical criteria will be denied.