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Does Blue Shield of California Cover Orlistat (Xenical, Alli)

Discover if Blue Shield covers Orlistat. Learn why it might deny coverage, how to obtain it, cost without insurance, and FAQs in a comprehensive guide.
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Coverage Criteria for Orlistat (Xenical, Alli) by Blue Shield of California

 

  • Blue Shield of California typically covers Orlistat based on medical necessity, which often requires documentation from your healthcare provider indicating its necessity for obesity-related medical conditions.

    •  

  • Prescription coverage may apply to Xenical (prescription strength Orlistat), while Alli (over-the-counter version) might not be covered.

    •  

  • Prior authorization is usually required. This means your healthcare provider needs to submit a request with supporting medical documentation to demonstrate the need for Orlistat.

    •  

  • Criteria often include a body mass index (BMI) that qualifies for weight-loss medication or a high-risk medical condition related to obesity, such as hypertension or diabetes.

    •  

  • Coverage details can vary for different plans under Blue Shield of California, so it’s crucial to check your specific plan details or contact customer service for the most accurate information.

 

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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 Shield of California

 

Contact Blue Shield of California Customer Service

 

  • Start by calling the Blue Shield of California customer service number found on the back of your insurance card to confirm your policy details and coverage specifics regarding weight loss medications like Orlistat.

    •  

  • Inquire if Orlistat (Xenical, Alli) is covered under your current plan and what requirements need to be met for coverage.

 

Review Your Plan's Formulary

 

  • Access the Blue Shield of California website or contact customer support to get a copy of your plan’s formulary, which lists medications covered by your insurance.

    •  

  • Check if Orlistat (Xenical, Alli) is included in the formulary and the specific tier it falls under. Higher tiers may require higher copayments or additional authorization.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your weight loss goals and the appropriateness of Orlistat for your situation.

    •  

  • Your healthcare provider can prescribe Orlistat if deemed suitable and assist with any necessary steps required by your insurance for coverage.

 

Obtain Prior Authorization

 

  • If required, your healthcare provider will need to submit a prior authorization request to Blue Shield of California to justify the medical necessity of Orlistat for you.

    •  

  • Ensure your healthcare provider includes detailed documentation supporting the request, such as your BMI, medical history, and previous weight loss attempts.

 

Follow Up on Authorization Request

 

  • After your provider submits the prior authorization, proactively follow up with Blue Shield of California to monitor the request's status.

    •  

  • Be prepared to provide any additional information the insurance company may request to support your coverage request.

 

Review Coverage Decision

 

  • You will receive a notice regarding the approval or denial of your prior authorization request. If approved, the notice will detail any copayment or coinsurance you must pay.

    •  

  • If denied, review the reasons provided and discuss potential next steps with your healthcare provider, such as submitting an appeal or considering alternative treatments.

 

Appeal a Denied Request

 

  • If your request is denied, consult with your healthcare provider to determine if filing an appeal is appropriate. Gather any additional documentation or information to strengthen your case.

    •  

  • Submit your appeal to Blue Shield of California, following their specific process and submission requirements to ensure a complete and timely review.

 

Utilize Blue Shield of California Resources

 

  • Take advantage of any additional resources provided by Blue Shield of California, such as a case manager or patient advocate, to assist with navigating the coverage process.

    •  

  • Stay informed about changes to your insurance plan or state regulations that may impact coverage for weight loss medications.

 

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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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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 Shield of California Cover Orlistat (Xenical, Alli)

Discover if Blue Shield covers Orlistat. Learn why it might deny coverage, how to obtain it, cost without insurance, and FAQs in a comprehensive guide.
Achieve Your Goals Faster with Curex
Curex allergy drops unboxing

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

 

Coverage Criteria for Orlistat (Xenical, Alli) by Blue Shield of California

 

  • Blue Shield of California typically covers Orlistat based on medical necessity, which often requires documentation from your healthcare provider indicating its necessity for obesity-related medical conditions.

    •  

  • Prescription coverage may apply to Xenical (prescription strength Orlistat), while Alli (over-the-counter version) might not be covered.

    •  

  • Prior authorization is usually required. This means your healthcare provider needs to submit a request with supporting medical documentation to demonstrate the need for Orlistat.

    •  

  • Criteria often include a body mass index (BMI) that qualifies for weight-loss medication or a high-risk medical condition related to obesity, such as hypertension or diabetes.

    •  

  • Coverage details can vary for different plans under Blue Shield of California, so it’s crucial to check your specific plan details or contact customer service for the most accurate information.

 

A weight management program tailored to you

Start with Curex

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

 

Eligibility Criteria for Orlistat Coverage

 

  • The patient has been diagnosed with obesity, defined as a BMI (Body Mass Index) of 30 or greater, or overweight with a BMI of 27 or greater with associated risk factors or comorbidities.

    •  

  • Documentation of participation in a comprehensive weight management program, including a calorie-controlled diet and increased physical activity, is required.

    •  

  • Orlistat is prescribed as an additional aid to a reduced-calorie diet and increased physical activity for weight management and weight loss maintenance.

 

Prescription Requirements

 

  • A licensed healthcare provider must prescribe Orlistat for weight management, explicitly indicating it as part of the complete treatment plan.

    •  

  • A treatment plan including specific dietary changes and physical activity recommendations must accompany the prescription.

 

Follow-up and Ongoing Evaluation

 

  • Regular follow-up appointments must be scheduled to monitor the patient's progress and response to Orlistat in conjunction with the weight management program.

    •  

  • Evidence of weight loss or improvement in related health conditions must be documented to continue coverage.

    •  

  • Periodic reassessment of the patient's condition and treatment efficacy is required to ensure ongoing conformity with coverage criteria.

 

Age and Health Considerations

 

  • Orlistat coverage is generally considered for adults aged 18 and above unless specific pediatric guidelines and risks are assessed by a specialist.

    •  

  • The patient must not have conditions contraindicated for Orlistat usage, such as chronic malabsorption syndrome or cholestasis.

 

Provider Network and Pharmacy Plan

 

  • Orlistat prescriptions must be processed through the Blue Shield of California's network of approved pharmacies.

    •  

  • Insurance for Orlistat may require prior authorization, and specific pharmacy benefits or formulary tier placement can impact the coverage.

 

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

 

Situations Where Blue Shield of California Might Deny Orlistat Coverage

 

  • Non-Compliance with BMI Requirements: Coverage might be denied if the patient's Body Mass Index (BMI) does not meet the company's minimum requirement for prescription weight loss medications.

    •  

  • Lack of Documented Weight Management Efforts: If there is insufficient documentation of prior attempts at weight management, Blue Shield may deny Orlistat coverage. This includes failed diets, exercise programs, or other lifestyle modification attempts.

    •  

  • Absence of a Clinical Diagnosis of Obesity: If Orlistat is prescribed for reasons other than a clinically diagnosed obesity condition, coverage could be denied. The diagnosis must be documented and align with the company's policy guidelines.

    •  

  • Use for Cosmetic Weight Loss: Coverage may be denied if Orlistat is used primarily for cosmetic weight loss purposes rather than for medically necessary reasons.

    •  

  • Use Outside of FDA-Approved Indications: Blue Shield might not cover Orlistat if it is prescribed for off-label uses that are not FDA-approved or if the prescription reasons fall outside of established medical guidelines.

    •  

  • Failure to Meet Age or Preauthorization Criteria: Denial can occur if the patient does not meet specific age criteria or if necessary preauthorization steps are not completed as required by Blue Shield.

    •  

  • Dose Not Within Specified Guidelines: If the prescribed dose of Orlistat falls outside the recommended guidelines set by Blue Shield policies, coverage may be denied.

    •  

 

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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 Shield of California

 

Contact Blue Shield of California Customer Service

 

  • Start by calling the Blue Shield of California customer service number found on the back of your insurance card to confirm your policy details and coverage specifics regarding weight loss medications like Orlistat.

    •  

  • Inquire if Orlistat (Xenical, Alli) is covered under your current plan and what requirements need to be met for coverage.

 

Review Your Plan's Formulary

 

  • Access the Blue Shield of California website or contact customer support to get a copy of your plan’s formulary, which lists medications covered by your insurance.

    •  

  • Check if Orlistat (Xenical, Alli) is included in the formulary and the specific tier it falls under. Higher tiers may require higher copayments or additional authorization.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your weight loss goals and the appropriateness of Orlistat for your situation.

    •  

  • Your healthcare provider can prescribe Orlistat if deemed suitable and assist with any necessary steps required by your insurance for coverage.

 

Obtain Prior Authorization

 

  • If required, your healthcare provider will need to submit a prior authorization request to Blue Shield of California to justify the medical necessity of Orlistat for you.

    •  

  • Ensure your healthcare provider includes detailed documentation supporting the request, such as your BMI, medical history, and previous weight loss attempts.

 

Follow Up on Authorization Request

 

  • After your provider submits the prior authorization, proactively follow up with Blue Shield of California to monitor the request's status.

    •  

  • Be prepared to provide any additional information the insurance company may request to support your coverage request.

 

Review Coverage Decision

 

  • You will receive a notice regarding the approval or denial of your prior authorization request. If approved, the notice will detail any copayment or coinsurance you must pay.

    •  

  • If denied, review the reasons provided and discuss potential next steps with your healthcare provider, such as submitting an appeal or considering alternative treatments.

 

Appeal a Denied Request

 

  • If your request is denied, consult with your healthcare provider to determine if filing an appeal is appropriate. Gather any additional documentation or information to strengthen your case.

    •  

  • Submit your appeal to Blue Shield of California, following their specific process and submission requirements to ensure a complete and timely review.

 

Utilize Blue Shield of California Resources

 

  • Take advantage of any additional resources provided by Blue Shield of California, such as a case manager or patient advocate, to assist with navigating the coverage process.

    •  

  • Stay informed about changes to your insurance plan or state regulations that may impact coverage for weight loss medications.

 

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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