CurrentUnitedHealthcarePolicy N/A

Egrifta (tesamorelin) prior authorization

Defines UnitedHealthcare prior authorization and reauthorization requirements for Egrifta SV and Egrifta WR (tesamorelin) for treatment of HIV-associated lipodystrophy; applies to members whose benefits require prior authorization.

Policy Summary

PayerUnitedHealthcare

PolicyEgrifta (tesamorelin) prior authorization

Policy CodePolicy N/A

Change TypeProgram updateauthorization timing revised

Effective DateJan 1, 2026

Next Review DateOct 1, 2025

Key ActionSubmit prior authorization documenting diagnosis of HIV-associated lipodystrophy; initial approvals issued for 12 months.

SourceLink

POLICY UPDATE CHANGES

Egrifta WR was added to the program.

Initial authorization duration updated to 12 months.

Reauthorization duration updated to 12 months.

12 monthsInitial authorization duration

12 monthsReauthorization duration

Egrifta SV, Egrifta WRDrugs covered

Not for weight lossLimitation of use

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Coverage Criteria for Egrifta (tesamorelin)

Initial Therapy — Covered when ALL of the following are met

Covered when ALL of the following are met

Initial Authorization: Diagnosis of HIV-associated lipodystrophy

Authorization issued for 12 months

Initial authorization — Initial coverage rule

Covered when ALL of the following are met

Initial: Diagnosis of HIV-associated lipodystrophy

12-month initial authorization

Continuation Therapy / Reauthorization — Covered when ALL of the following are met

Covered when ALL of the following are met

Reauthorization: Documentation of positive clinical response (e.g., improvement in visceral adipose tissue, decrease in waist circumference, belly appearance) while on therapy

Authorization issued for 12 months

Reauthorization — Reauthorization requires evidence of clinical benefit

Reauthorization requires evidence of clinical benefit

Reauthorization: Documentation of positive clinical response (e.g., improvement in visceral adipose tissue [VAT], decrease in waist circumference, belly appearance) while on Egrifta therapy

12-month reauthorization

Not indicated for weight loss management: Egrifta (tesamorelin) is not indicated for weight loss and should not be used for general weight reduction purposes. The policy excludes use for weight loss management as a limitation of use.

Use for weight loss is not supported: Use of Egrifta for weight loss management is not an indicated or supported use. The available evidence does not support prescribing Egrifta for this purpose.

Provider Requirements and Operational Notes

Prior Authorization

Prior Authorization Required

Prior authorization is required for initiation of Egrifta. Authorization will be approved only for members with a documented diagnosis of HIV-associated lipodystrophy. Initial authorizations are issued for a 12-month period.

Diagnosis: HIV-associated lipodystrophy
Initial authorization length: 12 months

Denial Risk

Automated Approval/Denial Risk

Requests may be approved or denied automatically based on program logic, prior claim or medication history, and diagnosis codes (ICD-10). Automated approval and re-approval processes vary by UnitedHealthcare program and therapeutic class; denials may occur if claims history or system logic do not support the request.

Automated decisions may rely on prior claims/medication history and ICD-10 diagnosis codes
Approval/denial logic and automation vary by program

Key Definitions

HIV-associated lipodystrophy definition

TermHIV-associated lipodystrophy

DefinitionRedistribution of body fat in HIV-infected patients, including excess abdominal (visceral) adipose tissue.

Related drug indicationIndication context: tesamorelin indicated to reduce excess abdominal (visceral) fat in HIV-infected patients with lipodystrophy.

Clinical Background

Tesamorelin is a growth hormone–releasing factor (GHRF) analog indicated to reduce excess abdominal (visceral) fat in patients with HIV-associated lipodystrophy. UnitedHealthcare’s coverage is limited to that indication; initial prior authorization requires a diagnosis of HIV-associated lipodystrophy, and approvals are issued with defined authorization periods (e.g., initial authorization for 12 months). The policy notes that long-term cardiovascular safety has not been established and that reauthorization requires documentation of a positive clinical response while on therapy.

Step Therapy / Prior Authorization Logic

Step	Requirement
1	No step therapy is specified for Egrifta (tesamorelin). UnitedHealthcare may apply supply limits or use automated prior-authorization/ re-approval logic based on prior claim/medication history, diagnosis codes, and/or program-specific claim logic.

Quantity and Supply Limits

Egrifta (tesamorelin) — utilization notes

DrugEgrifta (tesamorelin)

Quantity/Utilization ruleSupply limits may apply.

Automated processing noteUse of automated approval and re-approval processes varies by program and/or therapeutic class.

Authorization considerationUnitedHealthcare may approve initial and re-authorization based on prior claim/medication history, diagnosis codes, and/or claim logic.

Site-of-Care Considerations

Note

No site-of-care restriction specified for infusion center

No site-of-care restrictions are specified for infusion centers; however, the program may use automated approval processes depending on therapeutic class, so site-specific authorization rules should be confirmed.

No site-of-care restrictions specified
Program may use automated approval processes depending on therapeutic class

Policy Revision History

2026-01-01effective_date

Policy effective date set to 2026-01-01 per program header.

2025-10added_drug

Egrifta WR (tesamorelin) was added to the prior authorization program.

2025-02authorization_duration_change

Initial authorization length was standardized to 12 months.