orlistat 120 mg (Xenical, authorized generic) — Medica

Initial criteria

• age ≥ 12 years and < 18 years
• patient has engaged in behavioral modification and dietary restriction for at least 3 months
• baseline BMI ≥ 95th percentile for age and sex
• medication used concomitantly with behavioral modification and reduced-calorie diet

Reauthorization criteria

• age ≥ 12 years and < 18 years
• baseline BMI ≥ 95th percentile for age and sex
• patient has had a reduction in BMI percentile for age and weight (accounting for increased height)
• medication used concomitantly with behavioral modification and reduced-calorie diet

Approval duration

initial 3 months; reauth 1 year