Xenical (orlistat 120 mg) — Cigna

Initial criteria

• Patient is age ≥ 18 years; AND
• Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months; AND
• Patient meets ONE of the following (a or b): a) At baseline, BMI ≥ 30 kg/m2; OR b) BOTH [(1) and (2)]: (1) Baseline BMI ≥ 27 kg/m2; AND (2) Baseline or current ≥ 1 listed weight-related comorbidity; AND
• Medication will be used with behavioral modification and a reduced-calorie diet.

Reauthorization criteria

• Patient is age ≥ 18 years; AND
• Patient meets ONE of the following (a or b): a) At baseline, BMI ≥ 30 kg/m2; OR b) BOTH [(1) and (2)]: (1) Baseline BMI ≥ 27 kg/m2; AND (2) Baseline or current ≥ 1 listed weight-related comorbidity; AND
• Medication will be used with behavioral modification and a reduced-calorie diet.

Approval duration

initial 3 months; reauth 1 year