Egrifta SV — Cigna

Initial criteria

• Patient age ≥ 18 years; AND
• Medication is prescribed for the reduction of excess abdominal fat; AND
• Patient meets ONE of the following (a or b): a) If male, waist circumference ≥ 95 cm and waist-to-hip ratio ≥ 0.94; OR b) If female, waist circumference ≥ 94 cm and waist-to-hip ratio ≥ 0.88; AND
• Patient has been stable on an antiretroviral regimen for at least 8 weeks; AND
• Medication is prescribed by or in consultation with an endocrinologist or a physician specializing in the treatment of HIV infection (e.g., infectious disease, oncology)

Reauthorization criteria

• Patient is currently receiving Egrifta and has responded, as determined by the prescriber (e.g., reduction in visceral adipose tissue measured by waist circumference or computed tomography scan)

Approval duration

initial 6 months, renewal 1 year