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Xenical — Blue Cross Blue Shield of Alabama

obesity

Initial criteria

  • Patient is adult (age ≥ 18 years) AND ALL of the following:
  • • ONE of: BMI ≥ 30 kg/m^2 OR BMI ≥ 25 kg/m^2 if South Asian, Southeast Asian, or East Asian descent OR BMI ≥ 27 kg/m^2 with ≥1 weight-related comorbidity (e.g., diabetes, dyslipidemia, coronary artery disease)
  • • Has been on weight loss regimen (low-calorie diet, increased physical activity, behavioral modifications) ≥ 6 months prior to initiation
  • • Will continue weight loss regimen during therapy
  • OR
  • Patient is pediatric (age 12–17 years) AND ALL of the following:
  • • ONE of: BMI ≥ 95th percentile for age/gender OR BMI ≥ 30 kg/m^2 OR BMI ≥ 85th percentile for age/gender with ≥1 weight-related comorbidity (e.g., hypertension, dyslipidemia, type 2 diabetes, obstructive sleep apnea)
  • • Has been on weight loss regimen ≥ 6 months prior to initiation
  • • Will continue weight loss regimen during therapy
  • AND
  • • Age is within FDA labeling or supported for requested agent
  • AND
  • • ONE of: patient has NOT tried a targeted weight loss agent in past 12 months OR has tried a targeted agent and prescriber anticipates success with repeating therapy
  • AND
  • • ONE of:
  • - Requested agent is benzphetamine, diethylpropion, phendimetrazine, or phentermine
  • - Requested agent is Qsymia AND ONE of:
  • • Requested dose is 3.75 mg/23 mg OR
  • • Currently treated on >3.75 mg/23 mg dose AND ONE of: pediatric with ≥5% baseline BMI reduction OR adult with ≥5% weight loss from baseline OR received <14 weeks therapy OR dose titration upward OR <12 weeks on highest strength (15 mg/92 mg) OR support for therapy
  • - Requested agent is Contrave AND ONE of: newly starting therapy OR currently treated <16 weeks OR achieved ≥5% weight loss from baseline
  • - Requested agent is Xenical/Orlistat AND ONE of:
  • • Age 12–16 years AND one of: newly starting OR treated <12 weeks OR achieved >4% weight loss from baseline
  • • Age ≥17 years AND one of: newly starting OR treated <12 weeks OR achieved ≥5% weight loss from baseline
  • AND
  • • Patient will NOT use in combination with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound)
  • • No FDA labeled contraindications to requested agent

Reauthorization criteria

  • Patient previously approved through plan’s Prior Authorization process
  • AND
  • • ONE of:
  • - For Qsymia:
  • • Pediatric (age 12–17 years): achieved and maintained ≥5% baseline BMI reduction OR
  • • (Pediatric or adult) achieved and maintained <5% reduction AND BOTH: dose titrated upward AND received <12 weeks on highest strength (15 mg/92 mg)
  • - For Xenical/Orlistat:
  • • Age 12–16 years: achieved and maintained >4% baseline weight loss
  • • Age ≥17 years: achieved and maintained ≥5% baseline weight loss
  • - For any requested agent: achieved and maintained ≥5% baseline weight loss
  • AND
  • If pediatric: current BMI >85th percentile for age/gender
  • AND
  • Currently on and will continue low-calorie diet, increased physical activity, behavioral modifications
  • AND
  • Will not use with another weight loss agent (e.g., Contrave, phentermine, Qsymia, Xenical, Saxenda, Wegovy, Zepbound)
  • No FDA labeled contraindications to requested agent

Approval duration

3 months