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Xenical — Highmark

to 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 submits attestation of baseline and current height, weight, and BMI
  • baseline BMI ≥ 30 kg/m2 OR baseline BMI ≥ 27 kg/m2 with a weight-related comorbidity (e.g., hypertension, cardiovascular disease, dyslipidemia, obstructive sleep apnea)
  • prescriber attests member will use product in combination with a lifestyle modification program that encourages reduced calorie diet and increased physical activity
  • prescriber attests member actively participated for at least 3 months prior to initiation in a lifestyle modification program that encourages reduced calorie diet and increased physical activity