orlistat 120 mg (Xenical, authorized generic) — Medical Mutual

Initial criteria

• Patient is ≥ 18 years of age; AND
• Patient has BMI ≥ 30 kg/m2 OR BMI ≥ 27 kg/m2 with comorbidities besides obesity; OR had an initial BMI ≥ 30 kg/m2 OR ≥ 27 kg/m2 with comorbidities if maintaining weight loss; AND
• Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months and has failed to achieve the desired weight loss; AND
• Patient is currently engaged in behavioral modification and on a reduced calorie diet

Reauthorization criteria

• Patient is ≥ 18 years of age; AND
• Patient had an initial BMI ≥ 30 kg/m2 OR a BMI ≥ 27 kg/m2 with comorbidities besides obesity; AND
• Patient is currently engaged in behavioral modification and on a reduced calorie diet; AND
• Patient has lost ≥ 5% of baseline body weight

Approval duration

3 months initial, 1 year continuation