Egrifta SV — Medical Mutual

Initial criteria

• Patient age ≥ 18 years
• No disruption of the hypothalamic-pituitary axis due to hypophysectomy, hypopituitarism, pituitary tumor/surgery, head irradiation, or head trauma
• No active malignancy
• Patient is not pregnant
• Drug prescribed by or in consultation with an endocrinologist or HIV specialist
• Drug is prescribed for the reduction of excess abdominal fat
• If male, waist circumference ≥ 95 cm (37.4 in) AND waist-to-hip ratio ≥ 0.94 OR If female, waist circumference ≥ 94 cm (37 in) AND waist-to-hip ratio ≥ 0.88
• Stable on an anti-retroviral regimen for at least 8 weeks

Reauthorization criteria

• Patient age ≥ 18 years
• Patient is not pregnant
• Drug prescribed by or in consultation with an endocrinologist or HIV specialist
• Patient has shown evidence of improvement based on waist circumference or CT scan

Approval duration

6 months initial, 6 months reauth