Does EmblemHealth Cover Orlistat (Xenical, Alli)

Discover if EmblemHealth covers Orlistat, learn reasons for coverage denial, find out costs, and explore how to secure coverage effectively.
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Coverage Criteria for Orlistat (Xenical, Alli)

 

  • EmblemHealth typically covers Orlistat under prescription drug plans, but prior authorization may be required.
  •  

  • Coverage is usually for individuals diagnosed with obesity, where body mass index (BMI) is equal to or greater than 30 kg/m², or with a BMI of 27 kg/m² in the presence of risk factors like diabetes or hypertension.
  •  

  • Doctors must provide documentation proving Orlistat's medical necessity as part of a comprehensive weight loss program including diet and exercise.
  •  

  • Patients might need to demonstrate an inadequate response to lifestyle changes alone before EmblemHealth covers Orlistat.
  •  

 

General Rules

 

  • EmblemHealth requires the use of in-network pharmacies to obtain covered medications at lower costs.
  •  

  • Beneficiaries should review specific plan details as coverage can vary, especially for different plan tiers and benefit options.
  •  

  • Regular follow-ups and progress assessments might be necessary to continue receiving coverage for Orlistat under EmblemHealth.

 

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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.

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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.

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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 EmblemHealth

 

Verify Your Plan Details

 

  • Start by reviewing your EmblemHealth plan documentation or logging into your EmblemHealth account to check if your specific plan provides any coverage for weight-loss medications, including Orlistat (Xenical or Alli).
  • If you have difficulties finding this information, you can contact EmblemHealth customer service directly for assistance to understand your plan benefits.

 

Consult with Your Healthcare Provider

 

  • Speak with your healthcare provider about the potential benefits and necessity of taking Orlistat for your medical condition.
  • Your healthcare provider can provide a prescription and justification for the medication, which is often required for insurance coverage.

 

Request a Prior Authorization

 

  • Many health insurance plans, including EmblemHealth, require prior authorization to cover weight-loss medications. Your healthcare provider's office typically handles this process on your behalf.
  • Ensure that your doctor's office submits a thorough and complete prior authorization request with supporting documentation that highlights the medical necessity of Orlistat.

 

Submit Claims for Reimbursement

 

  • If you purchase Orlistat out-of-pocket and your insurance plan provides coverage, you may need to submit a claim for reimbursement.
  • Collect all necessary documentation, such as receipts of purchase and the prior authorization documents, then submit these to EmblemHealth as per the guidelines set by your insurance plan.

 

Appeal Denied Claims

 

  • If your request for coverage or reimbursement is initially denied, don't give up. Review the denial letter for specific reasons and gather any additional information that may strengthen your case.
  • File an appeal with EmblemHealth, providing additional documentation or justification from your healthcare provider as necessary.
  • Persist through the appeals process and keep communication lines open with both your doctor's office and EmblemHealth representatives.

 

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FAQs

Does EmblemHealth Cover Orlistat (Xenical, Alli)

Discover if EmblemHealth covers Orlistat, learn reasons for coverage denial, find out costs, and explore how to secure coverage effectively.
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Is Orlistat (Xenical, Alli) Covered by EmblemHealth

 

Coverage Criteria for Orlistat (Xenical, Alli)

 

  • EmblemHealth typically covers Orlistat under prescription drug plans, but prior authorization may be required.
  •  

  • Coverage is usually for individuals diagnosed with obesity, where body mass index (BMI) is equal to or greater than 30 kg/m², or with a BMI of 27 kg/m² in the presence of risk factors like diabetes or hypertension.
  •  

  • Doctors must provide documentation proving Orlistat's medical necessity as part of a comprehensive weight loss program including diet and exercise.
  •  

  • Patients might need to demonstrate an inadequate response to lifestyle changes alone before EmblemHealth covers Orlistat.
  •  

 

General Rules

 

  • EmblemHealth requires the use of in-network pharmacies to obtain covered medications at lower costs.
  •  

  • Beneficiaries should review specific plan details as coverage can vary, especially for different plan tiers and benefit options.
  •  

  • Regular follow-ups and progress assessments might be necessary to continue receiving coverage for Orlistat under EmblemHealth.

 

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EmblemHealth's Approved Criteria for Orlistat (Xenical, Alli) Coverage

 

Criteria for EmblemHealth's Orlistat Coverage

 

  • **Clinical Indication:** Orlistat is covered for members with a clinical indication of obesity management, including the presence of other comorbid conditions such as hypertension, type 2 diabetes, or dyslipidemia. These should be documented through a recent health examination and a physician’s evaluation.
  •  

  • **Body Mass Index (BMI):** Coverage is approved for individuals with a BMI of 30 kg/m² or greater. If the BMI is between 27 kg/m² and 29.9 kg/m², the member must have at least one weight-related comorbid condition as outlined above.
  •  

  • **Age Requirement:** Candidates must be at least 18 years old. Adolescents aged 12-17 may be considered for coverage under specific medical supervision and additional documentation.
  •  

  • **Dietary Plan:** The member must be participating in a structured, supervised weight management program that includes a reduced-calorie and low-fat diet. Documentation of adherence to this plan is required, and it should be monitored regularly by healthcare professionals.
  •  

  • **Documentation:** There should be clear documentation of previous weight loss trials and lifestyle modification attempts, including diet and exercise, without pharmaceutical intervention, over a period of at least six months.
  •  

  • **Prescribing Physician:** The medication must be prescribed by a healthcare provider specializing in obesity management or a general practitioner with experience in weight management therapy.
  •  

  • **Continued Treatment Efficacy:** For ongoing coverage, evidence of weight loss of at least 5% of initial body weight within three months of starting Orlistat is required. If not achieved, further evaluation and possible discontinuation will be considered unless medically justified.
  •  

  • **Additional Health Considerations:** The patient must not have contraindications such as chronic malabsorption syndrome or cholestasis. An assessment of other medications being taken should be conducted to prevent possible adverse interactions.

 

Why EmblemHealth Might Deny Orlistat (Xenical, Alli) Coverage

 

Criteria for Denying Orlistat Coverage by EmblemHealth

 

  • EmblemHealth may deny coverage if Orlistat (Xenical, Alli) does not meet the plan's medical necessity criteria. This includes situations where weight loss medications are not deemed medically necessary by the assessment of healthcare providers according to EmblemHealth's guidelines.
  •  

  • Coverage can be denied if the medication is prescribed for conditions other than those explicitly approved by EmblemHealth's guidelines, such as non-obesity related weight management.
  •  

  • EmblemHealth may also reject a claim if there is incomplete documentation or lack of information provided to justify the medical necessity of Orlistat, as per their policy requirements.
  •  

  • Claims for Orlistat may be denied if it is intended for use as an experimental or investigational treatment, as these are typically not covered by standard EmblemHealth plans.
  •  

  • If the patient has not met required preconditions set by their plan, such as failing to demonstrate tried alternative treatments or compliance with behavioral interventions, coverage may be denied.
  •  

  • Denial may occur if there are plan-specific exclusions for particular weight loss medications, including Orlistat, specified in the policy documentation.
  •  

 

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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.

 

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 EmblemHealth

 

Verify Your Plan Details

 

  • Start by reviewing your EmblemHealth plan documentation or logging into your EmblemHealth account to check if your specific plan provides any coverage for weight-loss medications, including Orlistat (Xenical or Alli).
  • If you have difficulties finding this information, you can contact EmblemHealth customer service directly for assistance to understand your plan benefits.

 

Consult with Your Healthcare Provider

 

  • Speak with your healthcare provider about the potential benefits and necessity of taking Orlistat for your medical condition.
  • Your healthcare provider can provide a prescription and justification for the medication, which is often required for insurance coverage.

 

Request a Prior Authorization

 

  • Many health insurance plans, including EmblemHealth, require prior authorization to cover weight-loss medications. Your healthcare provider's office typically handles this process on your behalf.
  • Ensure that your doctor's office submits a thorough and complete prior authorization request with supporting documentation that highlights the medical necessity of Orlistat.

 

Submit Claims for Reimbursement

 

  • If you purchase Orlistat out-of-pocket and your insurance plan provides coverage, you may need to submit a claim for reimbursement.
  • Collect all necessary documentation, such as receipts of purchase and the prior authorization documents, then submit these to EmblemHealth as per the guidelines set by your insurance plan.

 

Appeal Denied Claims

 

  • If your request for coverage or reimbursement is initially denied, don't give up. Review the denial letter for specific reasons and gather any additional information that may strengthen your case.
  • File an appeal with EmblemHealth, providing additional documentation or justification from your healthcare provider as necessary.
  • Persist through the appeals process and keep communication lines open with both your doctor's office and EmblemHealth representatives.

 

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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.

 

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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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