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

Initial criteria

• Patient is ≥ 12 years of age and < 18 years of age; AND
• Patient currently has a BMI ≥ 95th percentile for age and sex; AND
• Patient has engaged in a trial of behavioral modification and dietary restriction for at least 3 months and has failed to limit weight gain or modify comorbidities; AND
• Patient is currently engaged in behavioral modification and on a reduced calorie diet

Reauthorization criteria

• Patient is ≥ 12 years of age and < 18 years of age; AND
• Patient had an initial BMI ≥ 95th percentile for age and sex; AND
• Patient is currently engaged in behavioral modification and on a reduced calorie diet; AND
• Patient’s current BMI percentile has decreased for age and weight (accounting for growth in height)

Approval duration

3 months initial, 1 year continuation