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Does Blue Cross Blue Shield of Massachusetts Cover Orlistat (Xenical, Alli)

Explore Orlistat coverage by BCBS of Massachusetts, reasons for denial, ways to secure coverage, cost without insurance, and FAQs answered.
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Coverage for Orlistat (Xenical, Alli)

 

  • Blue Cross Blue Shield of Massachusetts may cover Orlistat prescriptions such as Xenical for weight loss treatment under specific circumstances.

    •  

  • Generally, coverage is considered for patients with a body mass index (BMI) ≥30, or ≥27 with additional risk factors like hypertension or diabetes.

    •  

  • Approval may require prior authorization to ensure medical necessity and verify that other weight management programs have been unsuccessful.

    •  

 

Basic Rules and Criteria

 

  • Patients may need to provide documentation supporting their diagnosis via medical records, and demonstrate adherence to a supervised weight reduction plan.

    •  

  • Over-the-counter version Alli might not be covered unless specified by a plan due to its non-prescription status.

    •  

  • Plans can vary, so members should check with Blue Cross Blue Shield customer service for their specific policy details and need for physician involvement in the request process.

 

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Clinical Support

Our team is here to help!

Dr. Neeta Ogden, MD

Curex is poised to revolutionize the way allergies are treated in America, expanding access to clinical care and treatments that can meaningfully improve patients quality of life.

Dr. Ravi Patel, VP Telemedicine

At Curex, our mission is to help people improve their health and quality of life by understanding their allergies and treating them at their source.We provide more than individualized prescription treatments; we provide individualized care.

Jill Hamburg, PA - C

Immunotherapy made simple.  We enable patients to receive personalized allergy care on their own time. No more waiting rooms.

Dr. Chet Tharpe, Medical Director

Curex has set the standard for the virtual allergy experience. From the comfort of their home, patients nationwide are able to receive a personalized treatment plan from an experienced clinician, aimed at treating the source of their allergies, not just the symptoms.

Kayla Mardaga, NP

Curex offers convenient at-home allergy testing options. Our goal is to determine if a patient would benefit from immunotherapy and then customize a treatment plan that can reduce both the symptoms and the reliance on allergy medications.

How to Get Orlistat (Xenical, Alli) Coverage with Blue Cross Blue Shield of Massachusetts

 

Getting Started with Blue Cross Blue Shield of Massachusetts

 

  • Contact Blue Cross Blue Shield of Massachusetts customer service by calling the number on the back of your insurance card to inquire about your plan's pharmacy benefits related to weight loss medications, specifically Orlistat (Xenical, Alli).

    •  

  • Check your plan’s formulary, which is a list of covered medications. This is usually available on the insurance provider's website or through their customer service. Confirm whether Orlistat is included and if there are any specific requirements or restrictions for coverage.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your need for Orlistat. They can assess whether the medication is appropriate for you and provide any necessary documentation or medical rationale required by your insurance provider.

    •  

  • Ask your healthcare provider to issue a prescription for Orlistat. Ensure that the provider notes any medical necessity if required by your plan’s policy.

 

Submit a Prior Authorization Request

 

  • If Orlistat requires prior authorization, your healthcare provider might need to help you submit a formal request. This often involves submitting additional medical information to justify the necessity of the medication.

    •  

  • Work with your healthcare provider’s office to ensure all paperwork is properly completed and submitted to Blue Cross Blue Shield of Massachusetts.

 

Review Your Coverage and Cost

 

  • Once prior authorization is granted, contact your pharmacy to check how much of the cost Blue Cross Blue Shield of Massachusetts will cover. Discuss any copay or out-of-pocket costs with the pharmacist.

    •  

  • If applicable, discuss with your doctor or pharmacist about any generic or lower-cost alternatives that might be covered under your plan, such as Alli (over-the-counter version of Orlistat).

 

Appeal If Denied

 

  • If coverage for Orlistat is denied, review the denial letter carefully to determine the reasons and gather any missing documentation or information that could support an appeal.

    •  

  • Submit an appeal through Blue Cross Blue Shield of Massachusetts’s formal appeals process, helping them understand why the coverage is essential based on your health situation. Your healthcare provider may assist you with this process.

 

Explore Additional Support Options

 

  • Inquire about any weight management programs or additional resources that Blue Cross Blue Shield of Massachusetts might offer to support your treatment plan, which may complement the use of Orlistat.

    •  

  • Regularly review your insurance plan documents or speak to a representative to stay updated on any changes in coverage for medications like Orlistat.

 

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Apply treatments in minutes from the comfort of your own home with under-the-tongue applications instead of shots or pills

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Sublingual immunotherapy delivers a higher dose of allergens over the course of treatment.

Potential for results in as few as 6 months

Individual results vary but some users have reported a noticeable difference in as few as 6-12 months since starting treatments

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FAQs

Does Blue Cross Blue Shield of Massachusetts Cover Orlistat (Xenical, Alli)

Explore Orlistat coverage by BCBS of Massachusetts, reasons for denial, ways to secure coverage, cost without insurance, and FAQs answered.
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Curex allergy drops unboxing

Is Orlistat (Xenical, Alli) Covered by Blue Cross Blue Shield of Massachusetts

 

Coverage for Orlistat (Xenical, Alli)

 

  • Blue Cross Blue Shield of Massachusetts may cover Orlistat prescriptions such as Xenical for weight loss treatment under specific circumstances.

    •  

  • Generally, coverage is considered for patients with a body mass index (BMI) ≥30, or ≥27 with additional risk factors like hypertension or diabetes.

    •  

  • Approval may require prior authorization to ensure medical necessity and verify that other weight management programs have been unsuccessful.

    •  

 

Basic Rules and Criteria

 

  • Patients may need to provide documentation supporting their diagnosis via medical records, and demonstrate adherence to a supervised weight reduction plan.

    •  

  • Over-the-counter version Alli might not be covered unless specified by a plan due to its non-prescription status.

    •  

  • Plans can vary, so members should check with Blue Cross Blue Shield customer service for their specific policy details and need for physician involvement in the request process.

 

A weight management program tailored to you

Start with Curex

Blue Cross Blue Shield of Massachusetts's Approved Criteria for Orlistat (Xenical, Alli) Coverage

 

Eligibility Criteria for Orlistat Coverage

 

  • Patients must have a diagnosis of obesity, defined as a body mass index (BMI) of 30 kg/m² or higher.

    •  

  • Alternatively, patients with a BMI of 27 kg/m² or higher may qualify if they have comorbid conditions such as hypertension, diabetes, or dyslipidemia.

 

Trial of Lifestyle Modification

 

  • Documentation of a sustained trial, typically 6 months, of lifestyle modification focusing on diet, exercise, and behavior therapy with inadequate weight loss or inability to maintain weight loss is required.

    •  

  • The lifestyle modification program must be comprehensive and supervised by a qualified healthcare professional.

 

Failure of Prior Weight Loss Medications

 

  • If applicable, there must be documentation of failure, intolerance, or contraindication to other weight loss medications, unless contraindicated or inappropriate.

    •  

  • Reasons for discontinuation of prior medications should be clearly documented in the patient's medical record.

 

Age Requirement

 

  • Orlistat coverage is generally approved for patients who are 18 years of age or older.

    •  

  • For patients under 18, the prescribing physician should provide detailed justification, indicating the potential benefits outweigh risks.

 

Prescriber Requirements

 

  • The prescribing healthcare provider must be an endocrinologist, internist, or other specialist with expertise in weight management.

    •  

  • A detailed medical history and physical examination should be documented by the prescriber.

 

Monitoring and Follow-up

 

  • The insurance coverage is contingent upon regular follow-up visits to assess efficacy and safety, typically at 3-6 month intervals.

    •  

  • The healthcare provider must document ongoing lifestyle modifications and weight management efforts, including dietary and exercise programs.

 

Documentation and Submissions

 

  • All documentation supporting the medical necessity of Orlistat, including but not limited to, patient medical history, previous treatments, and follow-up plans should be submitted to Blue Cross Blue Shield of Massachusetts.

    •  

  • Continued coverage may require periodic submission of updated medical records and treatment outcomes to ensure compliance with the approved criteria.

 

Why Blue Cross Blue Shield of Massachusetts Might Deny Orlistat (Xenical, Alli) Coverage

 

Situations Where Coverage for Orlistat (Xenical, Alli) Might Be Denied

 

  • **Non-Medical Necessity:** Blue Cross Blue Shield of Massachusetts might deny coverage if they determine that Orlistat is not medically necessary for the patient. This determination could be based on the patient's current health status, weight, or other factors indicating that this medication is not required for effective treatment.

    •  

  • **Non-Compliance with Policy Requirements:** If the patient does not meet specific plan requirements, such as prior attempt and failure of weight loss with lifestyle changes or other medications, coverage for Orlistat may be denied.

    •  

  • **Exclusion of Weight-Loss Drugs:** Some insurance plans include specific exclusions for weight-loss drugs, which means Orlistat could be excluded from coverage regardless of the patient's condition or need.

    •  

  • **Usage Beyond Approved Indications:** If Orlistat is prescribed for off-label use or conditions beyond FDA-approved indications and guidelines, coverage might be denied by the insurer.

    •  

  • **Duplicate Therapy:** In cases where a patient is already taking another similar medication for weight management, Blue Cross Blue Shield of Massachusetts might deny the additional prescription to avoid redundant or duplicate therapy.

    •  

  • **Lack of Prior Authorization:** If the healthcare provider did not obtain prior authorization from Blue Cross Blue Shield of Massachusetts before prescribing Orlistat, the claim for coverage might be denied.

    •  

  • **Non-Adherence to Weight Management Guidelines:** If there is evidence that the patient is not following prescribed weight management guidelines (diet, exercise regime), this could result in a denial of medication coverage.

 

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How Much Does Orlistat (Xenical, Alli) Cost without Insurance?

 

Cost of Orlistat (Xenical, Alli) Without Insurance

 

  • Xenical: The brand-name Orlistat, Xenical, can be quite expensive without insurance. Typically, the cost is around $800 to $1,000 for a supply of 90 capsules, with each capsule being 120 mg.

    •  

  • Alli: The over-the-counter version, Alli, is generally less expensive than its prescription counterpart. The price for Alli ranges from $50 to $100 for a supply of 120 capsules, with each capsule being 60 mg.

    •  

  • Generic Orlistat: While generic options may be available, they usually do not offer significant savings over the brand-name versions. The prices for generic Orlistat are often comparable to those of Alli, varying from $50 to $100 for a similar quantity.

    •  

  • Shopping Tips: Prices can vary depending on the pharmacy, location, and availability. Consider using pharmacy discount cards, online coupons, or comparing prices at different pharmacies to obtain the best deal.

    •  

  • Considerations: Always consult a healthcare provider before starting Orlistat, and discuss any potential insurance coverage or assistance programs they might recommend.

 

Clinical Support

Our team is here to help!

Dr. Neeta Ogden, MD

Curex is poised to revolutionize the way allergies are treated in America, expanding access to clinical care and treatments that can meaningfully improve patients quality of life.

Dr. Ravi Patel, VP Telemedicine

At Curex, our mission is to help people improve their health and quality of life by understanding their allergies and treating them at their source.We provide more than individualized prescription treatments; we provide individualized care.

Jill Hamburg, PA - C

Immunotherapy made simple.  We enable patients to receive personalized allergy care on their own time. No more waiting rooms.

Dr. Chet Tharpe, Medical Director

Curex has set the standard for the virtual allergy experience. From the comfort of their home, patients nationwide are able to receive a personalized treatment plan from an experienced clinician, aimed at treating the source of their allergies, not just the symptoms.

Kayla Mardaga, NP

Curex offers convenient at-home allergy testing options. Our goal is to determine if a patient would benefit from immunotherapy and then customize a treatment plan that can reduce both the symptoms and the reliance on allergy medications.

How to Get Orlistat (Xenical, Alli) Coverage with Blue Cross Blue Shield of Massachusetts

 

Getting Started with Blue Cross Blue Shield of Massachusetts

 

  • Contact Blue Cross Blue Shield of Massachusetts customer service by calling the number on the back of your insurance card to inquire about your plan's pharmacy benefits related to weight loss medications, specifically Orlistat (Xenical, Alli).

    •  

  • Check your plan’s formulary, which is a list of covered medications. This is usually available on the insurance provider's website or through their customer service. Confirm whether Orlistat is included and if there are any specific requirements or restrictions for coverage.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your need for Orlistat. They can assess whether the medication is appropriate for you and provide any necessary documentation or medical rationale required by your insurance provider.

    •  

  • Ask your healthcare provider to issue a prescription for Orlistat. Ensure that the provider notes any medical necessity if required by your plan’s policy.

 

Submit a Prior Authorization Request

 

  • If Orlistat requires prior authorization, your healthcare provider might need to help you submit a formal request. This often involves submitting additional medical information to justify the necessity of the medication.

    •  

  • Work with your healthcare provider’s office to ensure all paperwork is properly completed and submitted to Blue Cross Blue Shield of Massachusetts.

 

Review Your Coverage and Cost

 

  • Once prior authorization is granted, contact your pharmacy to check how much of the cost Blue Cross Blue Shield of Massachusetts will cover. Discuss any copay or out-of-pocket costs with the pharmacist.

    •  

  • If applicable, discuss with your doctor or pharmacist about any generic or lower-cost alternatives that might be covered under your plan, such as Alli (over-the-counter version of Orlistat).

 

Appeal If Denied

 

  • If coverage for Orlistat is denied, review the denial letter carefully to determine the reasons and gather any missing documentation or information that could support an appeal.

    •  

  • Submit an appeal through Blue Cross Blue Shield of Massachusetts’s formal appeals process, helping them understand why the coverage is essential based on your health situation. Your healthcare provider may assist you with this process.

 

Explore Additional Support Options

 

  • Inquire about any weight management programs or additional resources that Blue Cross Blue Shield of Massachusetts might offer to support your treatment plan, which may complement the use of Orlistat.

    •  

  • Regularly review your insurance plan documents or speak to a representative to stay updated on any changes in coverage for medications like Orlistat.

 

Premium Medication you can trust

Our weight loss medication is delivered straight to your doorstep from a state-licensed pharmacy within our reliable network, ensuring you receive your medication when you need it.

‍

Each pharmacy in our network undergoes rigorous third-party testing through FDA and DEA certified labs. These tests focus on four key elements, ensuring both safety and efficacy for our treatments.

Orlistat (Xenical, Alli) FAQ

1. What are the side effects of taking Orlistat?

 

Possible Side Effects of Orlistat

 

  • Gastrointestinal issues: Common effects include oily or fatty stools, increased defecation, and the urgent or difficult need to control bowel movements.

    •  

  • Abdominal discomfort: Some users experience pain or discomfort in the abdomen region.

    •  

  • Reduced absorption of fat-soluble vitamins: Orlistat can interfere with the absorption of vitamins A, D, E, and K. A multivitamin supplement is often recommended.

    •  

  • Allergic reactions: Though rare, symptoms may include itching, rash, or swelling, especially of the face, tongue, or throat.

    •  

  • Others: Some users report headaches, back pain, or flu-like symptoms.

 

2. How effective is Orlistat for weight loss?

 

Effectiveness of Orlistat

 

  • Orlistat aids weight loss by blocking the absorption of fats from the diet, reducing caloric intake. It can block approximately 25-30% of dietary fat.

    •  

  • Clinical studies suggest that Orlistat use for one year can result in an average weight loss of about 5-10% of initial body weight, when combined with a calorie-reduced diet.

    •  

  • It promotes modest weight loss over time and helps maintain weight loss. The effectiveness can improve with lifestyle changes such as increased physical activity and diet modifications.

    •  

  • Orlistat also has beneficial effects on cholesterol levels and may help reduce blood pressure.

 

3. Can I buy Orlistat over the counter?

 

Can I Buy Orlistat Over the Counter?

 

  • Orlistat is available in two forms: prescription strength (Xenical) and over-the-counter (Alli).

    •  

  • **Xenical**: This is the 120 mg version and requires a doctor's prescription. It's typically used for patients with a higher body mass index (BMI) or more specific medical conditions.

    •  

  • **Alli**: The 60 mg variant can be purchased over the counter in many countries, including the United States and the UK.

    •  

  • Even though Alli is accessible without a prescription, it is advised to consult with a healthcare professional before starting, to discuss its suitability and ensure proper usage.

    •  

 

Considerations Before Using Orlistat

 

  • Proper dietary changes are necessary when taking Orlistat to maximize effectiveness and reduce side effects.

    •  

  • Discuss your complete medical history and any other medications you are taking with your healthcare provider.

 

Have questions left?

‍

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A weight management program tailored to you

Initial Dosage

Your initial medication and dosage are carefully determined by doctors, taking into account your unique health profile. This ensures a personalized and safe treatment plan tailored to your specific needs.

Titration

We gradually adjust your dosage to reach the optimal therapeutic level, ensuring maximum effectiveness while minimizing potential side effects.

Additional Treatments

Our providers may also recommend medications such as metformin or supplements such as vitamin B12. We recognize the importance of managing side effects, so your care plan may include medication to alleviate them.

Got questions? We have answers.

Do your plans include prescriptions and medications?

Curex plans cover everything from reviewing your medical intake to providing prescription medications, with free shipping included. There are no extra or hidden charges. Prescriptions are issued only after a medical provider reviews your information to confirm that the medication is suitable for you. Our service includes continuous support and regular follow-ups to ensure your treatment stays on track.

Our clinicians may order labs and additional medications for you, which would not be covered by the plan but for which you can use your insurance.

Please note: Compounded medications are tailored to individual needs or used in case of shortages, but they are not FDA-approved for safety or effectiveness. A prescription is required. Results may vary from person to person.

What medications do your providers prescribe?

We prioritize a personalized approach to your health. If your medical provider prescribes medication, options may include GLP-1 treatments such as compounded semaglutide (the active ingredient in Wegovy®* and Ozempic®*). Our providers prescribe only combination treatments not available at your local pharmacy that may include vitamin B12, etc. to help you achieve your goals faster.

Depending on your treatment goals, other medications such as metformin may also be considered. We recognize the importance of managing side effects, so your care plan might include medication to ease symptoms like nausea. Your well-being is always our top priority!

Please note that compounded medications are customized to meet individual patient needs and are not FDA-approved for safety or effectiveness. A prescription is necessary. Results may vary from person to person.

Curex and its pharmacy partners do not have any association with Novo Nordisk.

Will I be prescribed semaglutide if I sign up?

Your health journey is unique, and we tailor our care to match. Any prescriptions, including semaglutide, will be based on the expert assessment of the medical provider matched with you through our platform. You can trust that your treatment plan will be personalized to fit your specific needs. And if semaglutide is not prescribed, we will provide a full refund.

What is compounded medication?

Compounding involves creating customized medications to meet the specific needs of individual patients. For instance, a patient may require a liquid version of a medication that is only available in tablet form. Pharmacies can also compound medications using FDA-approved drugs that are on the FDA’s shortage list.

These compounded medications are made by state-licensed pharmacies that follow both federal and state regulations, including quality standards. However, when compounded in accordance with these laws, these medications are not subject to FDA approval and are not evaluated for safety or effectiveness.

Is compounded medication the same as generic medication?

Compounded medications differ from generic drugs. Generics require FDA approval by demonstrating bio-equivalence to the brand-name drug. In contrast, compounded medications are not FDA-approved. They are made based on a personalized prescription that may not be commercially available elsewhere or when a drug appears on the FDA’s shortage list. Compounding pharmacies must have the proper licensed facilities and comply with state and federal regulations before dispensing these medications.

Is insurance required?

No, Curex doesn’t require insurance. We offer clear and simple pricing, along with affordable medication options, making it easy and accessible to take care of your health.

Can I pay with an FSA or HSA card?

Yes! You can pay with your HSA or FSA card.

How much does treatment cost?

Semaglutide Injections:

Prices for semaglutide start at only $149 per month for weekly doses of 0.25mg and 0.5mg. You can cancel anytime. Some people experience weight loss at these doses and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 1mg, 1.7mg and 2.4mg of semaglutide for an additional $50 per month for each plan.

Tirzepatide Injections:

Prices for tirzepatide start at only $249 per month for weekly doses of 2.5mg and 5mg of tirzepatide.You can cancel anytime. Some people experience weight loss at these doses and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 7.5mg, 10mg and 12.5mg of tirzepatide for an additional $100 per month for each plan.

Semaglutide Tablets:

Prices for semaglutide tablets start at only $149 per month for daily doses of 2mg. You can cancel anytime. Some people experience weight loss at this dose and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 4mg and 8mg of semaglutide daily for an additional $50 per month for each plan.

Tirzepatide Tablets:

Prices for tirzepatide start at only $199 per month for daily dosees of 3mg of tirzepatide. You can cancel anytime. Some people experience weight loss at these doses and higher doses aren't advisable due to a higher risk of side effects. If you need a higher dose to achieve your weight loss goals, we offer higher-dose plans for 6mg and 12 mg of tirzepatide daily for an additional $100 per month for each plan.

‍

Can you prescribe Ozempic®* or Wegovy®*?

Our providers focus on personalized medications and dosages that aren’t commercially available at your local pharmacy. While we don’t prescribe Ozempic®* or Wegovy®* directly, we may prescribe treatments containing the same active ingredient. These medications are specially compounded for you by a licensed pharmacy to meet your specific needs.

Are video visits with a provider required?

Our providers will review your information 100% online. Depending on where you live and the specifics of your medical history, our providers may require you to have a video visit or asynchronous visit via text message. If prescribed, you’ll get unlimited online access to message your provider as needed for follow-ups, adjustments, and answers to your questions.

What states do you serve?

Currently, we do not serve Arkansas, Connecticut, and New Mexico. However, we are always working to expand our reach, so stay in touch with us at hi@getcurex.com.

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Curex provides allergy care plans for allergies, asthma, eczema and pet allergies.

Curex providers may prescribe sublingual allergy drops that contain the same ingredients as allergy shots but are more convenient & affordable.
‍
Curex-affiliated medical practices are independently owned and operated by licensed physicians who provide services using the Curex telehealth platform.

Compounded medications have not been approved by the FDA and the FDA has not evaluated their safety or efficacy.

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