Egrifta WR — CareFirst (Caremark)
Reduction of excess abdominal fat in human immunodeficiency virus (HIV)-infected adult patients with lipodystrophy
Initial criteria
- Member has HIV infection and lipodystrophy
- Member is currently receiving antiretroviral therapy
- The requested medication will be used to reduce excess abdominal fat
- Medication must be prescribed by or in consultation with an infectious disease specialist
Reauthorization criteria
- Member has HIV infection and lipodystrophy
- Member is currently receiving antiretroviral therapy
- Member has demonstrated a clear clinical improvement from baseline that is supported by waist circumference measurement or computed tomography (CT) scan
Approval duration
6 months