CurrentCareSource Georgia MedicaidPolicy GA-MED-P-366579

Tesamorelin for HIV-Associated Lipodystrophy

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This policy governs pharmacy prior authorization and coverage of Egrifta SV and Egrifta WR (tesamorelin) for adult members with HIV-associated lipodystrophy and excess abdominal visceral fat. It applies to CareSource Georgia Medicaid members and requires specific clinical documentation for initial authorization and reauthorization.

Policy Summary

PayerCareSource Georgia Medicaid

PolicyTesamorelin for HIV-Associated Lipodystrophy

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial revision

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit pharmacy prior authorization for Egrifta SV or Egrifta WR with all required clinical documentation and provider attestations.

SourceLink

POLICY UPDATE CHANGES

Egrifta WR was added to the policy with its dosing and quantity limit.

Provider attestations were added confirming that treatment is not for simple obesity or weight loss and that the member does not have active malignancy.

Reauthorization criteria were revised to allow CT scan, waist circumference, or waist-to-hip ratio documentation to demonstrate reduction in excess visceral adipose tissue.

2Tesamorelin products covered

6 monthsInitial authorization

12 months

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CurrentCareSource Georgia MedicaidPolicy GA-MED-P-366579

Tesamorelin for HIV-Associated Lipodystrophy

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Sign up for caresourcegeorgia Policy GA-MED-P-366579 alerts

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Policy Summary

PayerCareSource Georgia Medicaid

PolicyTesamorelin for HIV-Associated Lipodystrophy

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial revision

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit pharmacy prior authorization for Egrifta SV or Egrifta WR with all required clinical documentation and provider attestations.

SourceLink

POLICY UPDATE CHANGES

Egrifta WR was added to the policy with its dosing and quantity limit.

Provider attestations were added confirming that treatment is not for simple obesity or weight loss and that the member does not have active malignancy.

Reauthorization criteria were revised to allow CT scan, waist circumference, or waist-to-hip ratio documentation to demonstrate reduction in excess visceral adipose tissue.

2Tesamorelin products covered

6 monthsInitial authorization

12 months

30 vials/30 daysEgrifta SV limit

4 vials/28 daysEgrifta WR limit

8 weeksStable antiretroviral treatment

Coverage Criteria

Initial Therapy

Covered for initial authorization when ALL of the following requirements are met:

ALL of the following

Member is at least 18 years of age.
Medication is prescribed by or in consultation with an infectious disease specialist or endocrinologist.
Member has a diagnosis of HIV-associated lipodystrophy with excess abdominal fat (visceral adipose tissue).
ONE of the following sex-specific criteria is met
- If male, member has documentation of waist circumference > 95 cm and waist-to-hip ratio > 0.94.
- If female, member has documentation of waist circumference > 94 cm and waist-to-hip ratio > 0.88.
Member has been stable on antiretroviral treatment for at least 8 weeks.
Provider attests the medication is not being prescribed for simple obesity or weight loss.
Provider attests the member does not have active malignancy.
Requested dosing and quantity are within the applicable product limits: Egrifta SV 1.4 mg subcutaneously once daily, limited to 30 vials per 30 days; or Egrifta WR 1.28 mg subcutaneously once daily, limited to 4 vials per 28 days.

Continuation Therapy

Covered for reauthorization when the following requirement is met:

ALL of the following

Chart notes document a reduction in excess visceral adipose tissue from baseline, demonstrated by at least ONE of the following: computed tomography (CT) scan, waist circumference, or waist-to-hip ratio.
If the reauthorization requirement is met, therapy may be approved for 12 months.

Egrifta SV and Egrifta WR (tesamorelin) have a weight-neutral effect and should not be prescribed for obesity or weight loss.

CareSource considers Egrifta SV and Egrifta WR (tesamorelin) not medically necessary for the treatment of conditions that are not listed in this document. For any other indication, please refer to the Off-Label policy.

Clinical Thresholds and Coding Details

Male waist circumference

ThresholdGreater than 95 cm

Applies toMale members

Authorization useRequired with a male waist-to-hip ratio greater than 0.94 for initial authorization

Male waist-to-hip ratio

ThresholdGreater than 0.94

Applies toMale members

Authorization useRequired with a male waist circumference greater than 95 cm for initial authorization

Provider Actions and Documentation

Prior Authorization

Pharmacy Prior Authorization Required

Pharmacy prior authorization is required for Egrifta SV and Egrifta WR (tesamorelin). Initial approval is available for 6 months when all applicable clinical criteria and quantity limits are met.

Egrifta SV: 1.4 mg subcutaneously once daily; quantity limit of 30 vials per 30 days.
Egrifta WR: 1.28 mg subcutaneously once daily; quantity limit of 4 vials per 28 days.

Documentation Required

Initial Authorization Documentation

For initial authorization, submit documentation supporting each clinical requirement for tesamorelin treatment of HIV-associated lipodystrophy with excess abdominal visceral adipose tissue.

Member is at least 18 years of age.
Medication is prescribed by or in consultation with an infectious disease specialist or endocrinologist.

Background

Egrifta SV and Egrifta WR (tesamorelin) are analogs of human growth hormone-releasing factor indicated to reduce excess abdominal visceral fat in adults with HIV-associated lipodystrophy. The products have a weight-neutral effect and selectively reduce visceral fat rather than subcutaneous fat.

Definitions

Lipoatrophy

DefinitionLoss of subcutaneous fat

Clinical contextA form of lipodystrophy

Relationship to treatmentMay occur alone, with lipohypertrophy, or as a mixed presentation

Lipohypertrophy

DefinitionAccumulation of excess visceral adipose tissue

Clinical contextA form of lipodystrophy

Treatment relevanceTesamorelin is indicated to reduce excess abdominal visceral fat associated with HIV lipodystrophy

Initial Tesamorelin Therapy

Initial authorization requires all listed clinical, prescribing, documentation, and attestation criteria.

Initial tesamorelin authorization

Applicable sex-specific measurements
- Male measurements: If male, documentation shows a waist circumference greater than 95 cm and a waist-to-hip ratio greater than 0.94.Waist circumference > 95 cm; waist-to-hip ratio > 0.94
- Female measurements: If female, documentation shows a waist circumference greater than 94 cm and a waist-to-hip ratio greater than 0.88.Waist circumference > 94 cm; waist-to-hip ratio > 0.88

Tesamorelin Reauthorization

Reauthorization requires documented reduction of excess visceral adipose tissue from baseline.

Response documentation: Chart notes show a reduction of excess visceral adipose tissue from baseline measured by a computed tomography (CT) scan, waist circumference, or waist-to-hip ratio.Reduction from baseline documented by CT scan OR waist circumference OR waist-to-hip ratio

One accepted measurement method must document the reduction; reauthorization is approved for 12 months when the requirement is met.

Quantity Limits

Egrifta SV

Quantity limit30 vials per 30 days

Dose1.4 mg subcutaneously once daily

ProductEgrifta SV

Egrifta WR

Quantity limit4 vials per 28 days

Dose1.28 mg subcutaneously once daily

ProductEgrifta WR

Policy Summary

PayerCareSource Georgia Medicaid

PolicyTesamorelin for HIV-Associated Lipodystrophy

Policy CodePolicy GA-MED-P-366579

Change TypeMaterial revision

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit pharmacy prior authorization for Egrifta SV or Egrifta WR with all required clinical documentation and provider attestations.

SourceLink

On This Page

Female waist circumference

ThresholdGreater than 94 cm

Applies toFemale members

Authorization useRequired with a female waist-to-hip ratio greater than 0.88 for initial authorization

Female waist-to-hip ratio

ThresholdGreater than 0.88

Applies toFemale members

Authorization useRequired with a female waist circumference greater than 94 cm for initial authorization

Stable antiretroviral treatment

Minimum durationAt least 8 weeks

TreatmentAntiretroviral treatment

Authorization useRequired for initial authorization

Member has HIV-associated lipodystrophy with excess abdominal visceral fat.

For a male member: waist circumference > 95 cm and waist-to-hip ratio > 0.94.

For a female member: waist circumference > 94 cm and waist-to-hip ratio > 0.88.

Member has been stable on antiretroviral treatment for at least 8 weeks.

Provider attests that the medication is not being prescribed for simple obesity or weight loss and that the member does not have active malignancy.

Documentation Required

Reauthorization Documentation

For reauthorization, chart notes must document a reduction in excess visceral adipose tissue from baseline. If this requirement is met, reauthorization may be approved for 12 months.

Use one accepted measurement method: computed tomography (CT) scan, waist circumference, or waist-to-hip ratio.

Denial Risk

Not for Obesity or Weight Loss

Tesamorelin has a weight-neutral effect and selectively reduces visceral fat; it does not reduce subcutaneous fat. Coverage may be denied when the medication is prescribed for simple obesity or weight loss.

Denial Risk

Active Malignancy Attestation Required

Coverage may be denied unless the provider attests that the member does not have active malignancy.

Denial Risk

Unlisted Indication

Egrifta SV and Egrifta WR are not medically necessary for conditions or indications not listed in this policy. For any other indication, refer to the applicable Off-Label policy.

Obesity

DefinitionAn increase in subcutaneous fat

DistinctionDistinguished from HIV-associated lipodystrophy in this policy

Tesamorelin useTesamorelin should not be prescribed for obesity or weight loss

Clinical, prescribing, and attestation requirements: Member is at least 18 years of age; medication is prescribed by or in consultation with an infectious disease specialist or endocrinologist; member has HIV-associated lipodystrophy with excess abdominal fat (visceral adipose tissue); member has been stable on antiretroviral treatment for at least 8 weeks; provider attests that medication is not being prescribed for simple obesity or weight loss; and provider attests that the member does not have active malignancy.Age >= 18; stable antiretroviral treatment >= 8 weeks