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orlistat 120 mg (Xenical, authorized generic) — Cigna

Weight Loss, Adult

Initial criteria

  • Patient has engaged in behavioral modification and dietary restriction for at least 3 months
  • At baseline, patient had body mass index (BMI) ≥ 30 kg/m2 OR at baseline patient had BMI ≥ 27 kg/m2 AND at baseline patient had, or currently has, at least ONE of the following weight-related comorbidities: hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, metabolic dysfunction-associated steatotic liver disease/non-alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease
  • Medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Reauthorization criteria

  • At baseline, patient had body mass index (BMI) ≥ 30 kg/m2 OR at baseline patient had BMI ≥ 27 kg/m2 AND at baseline patient had, or currently has, at least ONE of the following weight-related comorbidities: hypertension, type 2 diabetes, dyslipidemia, obstructive sleep apnea, cardiovascular disease, knee osteoarthritis, asthma, chronic obstructive pulmonary disease, metabolic dysfunction-associated steatotic liver disease/non-alcoholic fatty liver disease, polycystic ovarian syndrome, or coronary artery disease
  • Medication will be used concomitantly with behavioral modification and a reduced-calorie diet
  • Patient has lost ≥ 5% of baseline body weight (baseline prior to orlistat 120 mg [Xenical, authorized generic])