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Egrifta prior authorization criteria

Drug Egrifta (Tesamorelin) [EMD Serono]

  • Available as 1 mg in a single use vial for reconstitution
  • Dose is 2 mg subcutaneous once daily

FDA approved indication

Tesamorelin (Egrifta™) is a growth hormone releasing factor (GRF) analog indicated for the reduction of excess abdominal fat* in HIV-infected patients with lipodystrophy. Tesamorelin is not indicated for weight loss management. It has a weight neutral effect.

*Defined in clinical trials as 105 cm.


  1. Patient has been diagnosed with HIV associated-visceral adipose tissue (VAT) lipodystrophy with a waist circumference of at least 105 cm AND
  2. A baseline IGF-1 is logged AND
  3. An accurate baseline waist circumference is logged AND
  4. The first PA is limited to 3 fills AND
  5. At 3 months of therapy, if the IGF-1 level is 3 SD, then no more refills will be added AND
  6. At 3 months of therapy, if waist circumference has not been reduced, then no more refills will be added AND
  7. If neither (e) or (f), then 9 fills may be added.

Exclusion criteria

  1. Active malignancy
  2. Pregnancy (pregnancy category X)
  3. Patients with a disruption of the hypothalamic-pituitary axis due to hypophysectomy, hypopituitarism or pituitary tumor/surgery, head irradiation or head trauma
  4. Known hypersensitivity to Tesamorelin or Mannitol
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