CurrentHighmark West VirginiaPolicy N/A

Medication prior authorization form for Xenical (orlistat)

This document is a medication prior authorization form used by Highmark West Virginia to request coverage for Xenical (orlistat) and documents member, provider, medication, and clinical lifestyle modification information required for prior authorization decisions.

Policy Summary

PayerHighmark West Virginia

PolicyMedication prior authorization form for Xenical (orlistat)

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit a completed Medication Prior Authorization Form with required clinical documentation by fax to 1-866-240-8123 or mail to the Highmark SPECARE address.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7form sections/questions

1fax submissions

1mailing address

Xenicalspecific drug

Coverage Criteria and Form Requirements

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Form-based medical necessity support items

Coverage considerations documented via form fields (these are the criteria items requested to support medical necessity):

Lifestyle modification participation: Member will use Xenical in combination with a lifestyle modification program that encourages reduced calorie diet and increased physical activity (provider must indicate Yes/No and attach supporting documentation).Yes

Acceptable documentation: provider chart notes, recurring receipts for program subscriptions, dietary logs, recurring nutrition counseling receipts

Duration of prior lifestyle modification: Provider must specify how many months the member has actively participated in a lifestyle modification program prior to initiating Xenical and attach documentation.numeric months (entered by provider)

One form of documentation from each category (diet and physical activity) is required, provided monthly where applicable.

Prior weight-loss medication trials: Provider must list prior weight loss medications tried and failed with dates of therapy (if applicable).documented prior therapies with dates

Includes examples: Saxenda, Qsymia, Wegovy, Contrave, Zepbound, previous Xenical therapy.

Baseline clinical measures: Provider must provide baseline height, weight, and BMI prior to therapy (and current values if member already on a weight loss medication).values provided and supported by chart notes

Attach documentation such as chart notes.

Use for weight regain prevention: If Xenical is intended to reduce risk of weight regain after initial non-pharmacologic weight loss, provider must indicate intent and whether member has experienced at least 8% weight loss using non-pharmacologic therapy alone.Yes/No for intent and >=8% if applicable

Provider must check Yes/No and supply supporting documentation.

Clinical Thresholds and Coding-related Fields

Duration of prior lifestyle modification — provider-entered months

Field capturedProvider must specify the number of months the member has actively participated in a lifestyle modification program prior to initiating Xenical (enter numeric months)

Required documentationAttach supporting documentation for duration (one form from each category: diet and physical activity), provided monthly where applicable (e.g., recurring receipts, chart notes, dietary logs)

Examples of acceptable diet documentationProvider chart notes detailing dietary adjustments; recurring program subscription receipts (Noom, Weight Watchers, Omada, etc.); dietary logs; recurring nutrition counseling receipts

Examples of acceptable physical activity documentationProvider chart notes specifying type/duration/frequency; recurring gym membership receipts; wearable device summary reports; recurring personal trainer receipts

Weight loss for maintenance use — at least 8% (Yes/No)

Threshold for maintenance useMember must have experienced at least 8% weight loss using non-pharmacologic therapy alone (provider to indicate Yes/No)

Intent must be indicatedProvider must indicate whether Xenical will be used to reduce risk of weight regain after initial non-pharmacologic weight loss (Yes/No)

Supporting documentationIf yes, attach documentation supporting the reported >=8% non-pharmacologic weight loss (e.g., chart notes, weight records)

Provider Submission Requirements and Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required via submission of the Medication Prior Authorization Form. Submit one separate form for each medication. The form must include complete member, provider, and medication details and be faxed to 1-866-240-8123 or mailed with supporting documentation.

Fax: 1-866-240-8123
Mail: 120 Fifth Avenue, SPECARE, Pittsburgh, PA 15222
One form per medication
Complete ALL information on the form (provider, member, medication details)

Prior Authorization

Prior Medication Trials Required

Prior medication trials must be documented. List any prior weight-loss medications tried and failed with dates of therapy (examples: Saxenda, Qsymia, Wegovy, Contrave, Zepbound, previous Xenical therapy). Attach documentation to support prior trials.

Provide previous weight loss medications and dates of therapy
Examples: Saxenda, Qsymia, Wegovy, Contrave, Zepbound, prior Xenical
Attach chart notes or other documentation showing trials and outcomes

Documentation Required

Documentation Required to Support Lifestyle Modification and Clinical Data

Attach documentation supporting lifestyle modification and clinical data. One item from each category (Diet and Physical Activity) is required. Also attach chart notes or other documentation for weight-related comorbidities and baseline/current height, weight, and BMI as applicable.

Diet: provider chart notes detailing dietary adjustments/calorie deficit; recurring receipts for subscription programs (monthly); dietary log; recurring appointments for nutritional counseling (monthly documentation).
Physical Activity: provider chart notes specifying type, duration, frequency; recurring gym membership receipts with activity notes; summary report from wearable device showing activity (e.g., ≥3 times/week for ≥20 minutes); recurring personal trainer receipts with notes.
Document duration of participation in lifestyle modification program (months) and attach supporting documentation.
Attach chart notes to document weight-related comorbidities.
Attach documentation for baseline (prior to therapy) and current (if on therapy) height, weight, BMI.

Denial Risk

Provider Certification and Denial Risk

The submitting provider certifies that the information provided is true, accurate, and complete. Incomplete or inaccurate information may lead to denial. Payment is subject to member eligibility and authorization does not guarantee payment.

The prescribing physician (PCP or Specialist) should complete the form in most cases.
Provide physician address for notification.
Payment is subject to member eligibility; authorization does not guarantee payment.

Background and Purpose

This Medication Prior Authorization Form documents the member's participation in a lifestyle modification program—defined as activities that encourage a reduced calorie diet and increased physical activity—and captures baseline and on-therapy clinical measures (height, weight, BMI) and weight-related comorbidities to support initiation or continuation of Xenical (orlistat).

Providers must attach supporting documentation of lifestyle modification participation (for both diet and physical activity) such as chart notes, dietary logs, subscription or recurring receipts, wearable activity reports, or program attendance records. The form also requires the provider to indicate duration of prior lifestyle modification (in months) and to document prior weight-loss medication trials with dates when applicable.

The submitting provider certifies the information is true and accurate; incomplete or inaccurate documentation may lead to denial. Note: Payment is subject to member eligibility and authorization does not guarantee payment.

Key Definitions

Lifestyle modification program — definition and examples (reduced calorie diet plus increased physical activity)

DefinitionA lifestyle modification program encourages both a reduced calorie diet and increased physical activity (examples: nutritional counseling, participation in a comprehensive weight management program)

Diet examplesProvider chart notes detailing specific dietary adjustments or calorie deficit; recurring receipts for subscriptions (Noom, Weight Watchers, Vida, Omada, etc.); dietary logs; recurring nutrition counseling receipts

Physical activity examplesProvider chart notes specifying type/duration/frequency; recurring gym membership receipts; wearable device activity summaries; recurring personal trainer receipts

Documentation requirementOne form of documentation from each category (diet and physical activity) is required; provide monthly records where applicable