Skip to content
The Policy VaultThe Policy Vault

Xenical — Highmark

reduce risk of weight regain after weight loss

Initial criteria

  • age ≥ 12 years
  • using Xenical to reduce risk of weight regain after initial weight loss (ICD-10: E66.0, E66.3)
  • prescriber attests baseline and current height, weight, and BMI
  • baseline BMI ≥ 30 kg/m2 OR BMI ≥ 27 kg/m2 with weight-related comorbidity (e.g., hypertension, cardiovascular disease, dyslipidemia, obstructive sleep apnea)
  • prescriber attests use with lifestyle modification program (reduced calorie diet and increased physical activity)
  • prescriber attests active participation ≥ 3 months prior in lifestyle modification program
  • member has experienced ≥ 8% weight loss using non-pharmacologic therapy alone

Reauthorization criteria

  • age ≥ 12 years
  • using Xenical to reduce risk of weight regain after initial weight loss (ICD-10: E66.0, E66.3)
  • prescriber attests baseline and current height, weight, and BMI
  • baseline BMI ≥ 30 kg/m2 OR BMI ≥ 27 kg/m2 with weight-related comorbidity (e.g., hypertension, cardiovascular disease, dyslipidemia, obstructive sleep apnea)