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orlistat 120 mg (Xenical, authorized generic) — Cigna

Weight Loss, Pediatric

Initial criteria

  • Patient has engaged in behavioral modification and dietary restriction for at least 3 months
  • At baseline, patient had body mass index (BMI) ≥ 95th percentile for age and sex (baseline refers to baseline prior to orlistat 120 mg [Xenical, authorized generic])
  • Medication will be used concomitantly with behavioral modification and a reduced-calorie diet

Reauthorization criteria

  • At baseline, patient had body mass index (BMI) ≥ 95th percentile for age and sex (baseline refers to baseline prior to orlistat 120 mg [Xenical, authorized generic])
  • 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])