Medicare AdvantagePrior AuthMedium impact
Egrifta® (tesamorelin acetate) (Revised)
Humana·Infectious Disease, Internal Medicine·Medicare Advantage
Effective date
Jul 22, 2026
We identified it
Jul 22, 2026
Summary
Humana revised its Egrifta (tesamorelin acetate) pharmacy coverage policy for Medicare Advantage members with HIV-associated lipodystrophy. The policy maintains prior authorization requirements and reinforces three clinical eligibility criteria: confirmed HIV-associated lipodystrophy diagnosis, use of Egrifta for abdominal fat reduction, and prior/current use of protease inhibitors (PI) and/or nucleoside reverse transcriptase inhibitors (NRTI). The revision updates monitoring requirements for IGF-1 levels, glucose status, and retinopathy.
Action Required
By July 22, 2026: Billing team must ensure prior authorization workflows for Egrifta (tesamorelin) comply with the revised policy. Verification staff should confirm all three eligibility criteria are documented before submitting PA requests: (1) HIV-associated lipodystrophy diagnosis, (2) intended use for abdominal fat reduction, and (3) documented history of PI and/or NRTI therapy. Update internal prior authorization checklist and staff training materials to reflect the revised monitoring requirements (IGF-1 levels >3 SDS require therapy discontinuation; glucose and retinopathy monitoring mandatory). Flag claims lacking complete documentation of these three criteria for denial or rework. Providers should be notified of the July 22, 2026 effective date.