Medicare AdvantagePrior AuthMedium impact
Egrifta® (tesamorelin acetate) (Revised)
Humana·Infectious Disease, Internal Medicine, Pharmacy·Medicare Advantage
Effective date
Sep 24, 2025
We identified it
Jun 25, 2026
Summary
Humana revised its Egrifta® (tesamorelin acetate) prior authorization policy for Medicare Advantage members with HIV-associated lipodystrophy on September 24, 2025. The policy maintains three approval criteria: diagnosed HIV-associated lipodystrophy, use for abdominal fat reduction, and current or prior protease inhibitor/nucleoside reverse transcriptase inhibitor therapy. No changes to coverage criteria are evident, but this revision should be verified against the previous version to identify specific modifications.
Action Required
By September 30, 2025: Billing team must verify this revised policy is loaded in the prior authorization system and update internal references. For any Egrifta claims currently pending or submitted: (1) Confirm prior authorization requirements align with the three approval criteria listed; (2) Ensure all prior auth requests include documentation of HIV diagnosis, lipodystrophy diagnosis, and current/prior antiretroviral therapy (PI/NRTI); (3) Flag any claims for members >65 years old or without documented antiretroviral therapy history for manual review. Providers should be notified to include all three criteria in prior auth requests. Claims submitted without proper prior authorization will be denied. Reference the policy at https://dctm.humana.com/Mentor/Web/v.aspx?objectID=090009298a4c3727 for the current version; do not rely on printed copies.