Orlistat — Blue Cross Blue Shield of Illinois

Initial criteria

• Target Agent(s) will be approved when ALL the following are met:
• 1. ONE of the following:
• A. The patient is an adult (age ≥ 18 years) AND ALL of the following:
• 1. ONE of the following:
• A. The patient has a diagnosis of obesity confirmed by a pretreatment BMI ≥ 30 kg/m^2 OR a BMI ≥ 25 kg/m^2 if the patient is of South Asian, Southeast Asian, or East Asian descent OR
• B. The patient has a pretreatment BMI ≥ 27 kg/m^2 with at least one weight-related comorbidity/risk factor/complication (e.g., diabetes, dyslipidemia, coronary artery disease)