orlistat — CareFirst (Caremark)

Obesity management including weight loss and weight maintenance when used in conjunction with a reduced-calorie diet

Initial criteria

Drug will be used with a reduced-calorie diet AND increased physical activity
Patient has participated in a comprehensive weight management program encouraging behavioral modification, reduced-calorie diet, AND increased physical activity with continuing follow-up for ≥ 6 months prior to drug therapy
Patient has baseline BMI ≥ 30 kg/m2 OR baseline BMI ≥ 27 kg/m2 with at least one weight-related comorbid condition (e.g., hypertension, type 2 diabetes mellitus, dyslipidemia)

Drug will be used with a reduced-calorie diet AND increased physical activity
Patient has completed at least 6 months of therapy with the requested drug
Patient has lost ≥ 5% of baseline body weight OR has maintained initial 5% weight loss

12 months