CurrentCignaPolicy N/A

egrifta_prior_authorization_form

A payer-specific prior authorization form for Egrifta (tesamorelin acetate) used to request coverage/authorization, capture patient and prescriber information, clinical indications (lipodystrophy/HIV), prior therapy/stability, baseline and follow-up measurements, and dispensing/site of care information.

Policy Summary

PayerCigna

Policyegrifta_prior_authorization_form

Policy CodePolicy N/A

Change TypeAdministrative prior authorization form (no material coverage changes)

Effective Date

Next Review Date

Key ActionFax completed form to (855) 840-1678 or submit online via CoverMyMeds or SureScripts; complete all items marked with an asterisk to receive faxed outcome.

SourceLink

POLICY UPDATE CHANGES

No material clinical/coverage changes

v121919Form version/date

5 business daysStandard response time

Policy summary and purpose

This is a payer-specific prior authorization form for Egrifta (tesamorelin acetate) to request coverage/authorization and to collect required patient, prescriber, and clinical data for review. The form gathers indication information (lipodystrophy and symptomatic status), HIV diagnosis and attestations of antiretroviral stability, baseline anthropometric measures (waist circumference and waist-to-hip ratio), and follow-up response data for continuation requests (CT reduction in visceral adipose tissue, reductions in waist-to-hip ratio or waist circumference).

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Clinical information requested for authorization

Form collects clinical data points required for review; not a deterministic criteria tree but indicates items reviewers will consider.

ALL of the following

Is Egrifta being prescribed to reduce excess abdominal fat in a patient with lipodystrophy?
Yes/No (or specify diagnosis)
Does the patient have symptomatic lipodystrophy (for example, abdominal pain, shortness of breath)?
Yes/No
Does the patient have a diagnosis of HIV disease?
Yes/No
If HIV = Yes,
- Has the patient been stable on antiretroviral regimen for at least 8 weeks?stable on antiretroviral regimen for at least 8 weeks
  Yes/No
Prior to using Egrifta, record waist circumference
numeric value requested
Prior to using Egrifta, record waist-to-hip ratio
numeric value requested

Continued therapy follow-up data

For continuation requests the form asks for evidence of improvement versus baseline:

ANY of the following

Has a CT scan shown a reduction in visceral adipose tissue (VAT) thickness compared to baseline?
Yes/No
Has the patient had a reduction in waist-to-hip ratio compared to baseline measurement?
Yes/No
Has the patient had a reduction in waist circumference compared to baseline measurement?
Yes/No

Actions required from providers

Prior Authorization

Submit completed prior authorization form

Fax the completed prior authorization form or submit online; ensure all items marked with an asterisk are completed so Cigna can respond via fax.

(855) 840-1678 (fax)
Submit online via CoverMyMeds or SureScripts

Prior Authorization

Urgent request handling

For urgent requests, call the urgent line to expedite handling. Standard response time for prescription drug coverage requests is 5 business days.

(800) 882-4462 (urgent phone)

Documentation Required

Provide baseline clinical measurements

Record and submit baseline waist circumference and waist-to-hip ratio. For continuation requests, submit evidence of reduced visceral adipose tissue (VAT) on CT scan or reductions in waist circumference or waist-to-hip ratio compared to baseline.

Billing Rule

Site of acquisition and billing

Indicate where the medication will be obtained (Accredo specialty pharmacy, prescriber's office stock billed on a medical claim form, retail pharmacy, or home health/home infusion vendor). If a facility or doctor will dispense or administer the medication, provide facility name, address, tax ID, and state.

Documentation Required

HIV-specific documentation

If the patient has HIV, attest on the form to the HIV diagnosis and that the patient has been stable on an antiretroviral regimen for at least 8 weeks.