Does Fallon Community Health Plan (FCHP) Cover Orlistat (Xenical, Alli)

Explore FCHP's Orlistat coverage, reasons for denial, tips to secure coverage, costs without insurance, and answers to commonly asked questions.
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Coverage for Orlistat (Xenical, Alli)

 

  • Fallon Community Health Plan (FCHP) may cover Orlistat (Xenical, Alli) for FDA-approved indications related to weight management, especially for individuals who meet specific criteria for obesity treatment.
  •  

  • To qualify for coverage, patients typically need to be diagnosed with obesity, determined by a Body Mass Index (BMI) over a certain threshold, often >30, or >27 with comorbidities like hypertension or diabetes.
  •  

  • Coverage might require prior authorization, where a healthcare provider submits documentation justifying the medical necessity based on the patient’s health status and weight loss goals.
  •  

  • It is essential to check the specific plan details as coverage can vary, including differing co-pays or limitations on prescription length and quantities.

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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 Fallon Community Health Plan (FCHP)

 

Verify Plan Coverage

 

  • Check your current Fallon Community Health Plan (FCHP) benefits to determine if weight-loss medications like Orlistat (Xenical, Alli) are covered. You can do this by reviewing your plan's Summary of Benefits and Coverage (SBC) document.
  •  

  • Log in to your member account on the FCHP website to access your specific plan details and coverage information.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your weight-loss goals and the potential benefit of using Orlistat (Xenical, Alli).
  •  

  • If your provider deems it necessary, they will provide a prescription for Orlistat and potentially a supporting letter detailing the medical necessity for the medication.

 

Verify Prescription Requirements

 

  • Contact FCHP customer service to confirm if there are any pre-authorization or step therapy requirements for Orlistat coverage. Obtain necessary forms or information from FCHP if pre-authorization is needed.
  •  

  • Provide your healthcare provider with any forms or guidelines required by FCHP to complete the pre-authorization process successfully.

 

Submit a Pre-Authorization Request

 

  • Have your healthcare provider submit a pre-authorization request to FCHP. This includes your prescription, any required forms, and supporting documentation of medical necessity.
  •  

  • Ensure that all submitted information is complete and accurate to avoid delays in the pre-authorization process.
  •  

  • Monitor the status of your pre-authorization request by contacting FCHP or checking their online portal.

 

Appeal if Necessary

 

  • If FCHP denies coverage for Orlistat, review the denial letter for specific reasons and understand the appeal process outlined by FCHP.
  •  

  • Prepare an appeal with the assistance of your healthcare provider, including any additional documentation or evidence supporting the medical necessity of Orlistat.
  •  

  • Submit the appeal to FCHP within the specified timeframe provided in the denial notice. Follow up regularly to track the progress of your appeal.

 

Explore Alternative Options

 

  • If Orlistat remains uncovered, discuss alternative weight-loss medications or treatments with your healthcare provider that may be covered by your FCHP plan.
  •  

  • Consider contacting FCHP to review different health plan options that might better suit your needs and include the desired medication coverage.

 

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FAQs

Does Fallon Community Health Plan (FCHP) Cover Orlistat (Xenical, Alli)

Explore FCHP's Orlistat coverage, reasons for denial, tips to secure coverage, costs without insurance, and answers to commonly asked questions.
Curex allergy drops unboxing

Is Orlistat (Xenical, Alli) Covered by Fallon Community Health Plan (FCHP)

 

Coverage for Orlistat (Xenical, Alli)

 

  • Fallon Community Health Plan (FCHP) may cover Orlistat (Xenical, Alli) for FDA-approved indications related to weight management, especially for individuals who meet specific criteria for obesity treatment.
  •  

  • To qualify for coverage, patients typically need to be diagnosed with obesity, determined by a Body Mass Index (BMI) over a certain threshold, often >30, or >27 with comorbidities like hypertension or diabetes.
  •  

  • Coverage might require prior authorization, where a healthcare provider submits documentation justifying the medical necessity based on the patient’s health status and weight loss goals.
  •  

  • It is essential to check the specific plan details as coverage can vary, including differing co-pays or limitations on prescription length and quantities.

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Fallon Community Health Plan (FCHP)'s Approved Criteria for Orlistat (Xenical, Alli) Coverage

 

Criteria for Coverage of Orlistat (Xenical, Alli) under Fallon Community Health Plan (FCHP)

 

  • Member must be diagnosed with obesity, defined as a body mass index (BMI) of 30 kg/m² or greater.
  •  

  • Orlistat may also be covered for patients with a BMI of 27 kg/m² or greater if they have associated risk factors, such as hypertension, type 2 diabetes, or dyslipidemia.
  •  

  • Documentation must be provided showing that the patient has attempted weight loss through non-pharmacologic methods such as diet and exercise for at least six months without achieving significant weight loss.
  •  

  • A weight management plan that includes regular monitoring by a healthcare provider should be in place.
  •  

  • The provider must document that the patient understands the importance of adhering to a reduced-calorie diet and increased physical activity in conjunction with Orlistat therapy.
  •  

  • Clear documentation of not having contraindications for Orlistat use, such as chronic malabsorption syndrome or cholestasis, must be provided.
  •  

  • Orlistat prescriptions will be limited to a maximum daily dose as specified in clinical guidelines to ensure effective and safe use.

 

Monitoring and Continuation Criteria

 

  • Initial coverage will be granted for a period of three to six months, during which time the member’s progress will be evaluated.
  •  

  • Continued coverage is contingent upon documentation of a clinically significant weight loss (usually defined as losing at least 5% of body weight) during this period.
  •  

  • Documentation showing an ongoing commitment to the comprehensive weight management plan, including regular follow-up visits to monitor progress and address any issues, must be provided.

 

Why Fallon Community Health Plan (FCHP) Might Deny Orlistat (Xenical, Alli) Coverage

 

Reasons for Denial of Orlistat Coverage by Fallon Community Health Plan (FCHP)

 

  • Orlistat is not covered if the member does not meet the specific body mass index (BMI) criteria established by FCHP.
  •  

  • Coverage is denied if there is no documented evidence of participation in a structured weight loss program.
  •  

  • FCHP will not cover Orlistat if there is a lack of documented medical necessity as per their guidelines.
  •  

  • The plan does not cover Orlistat if it is prescribed for cosmetic weight loss purposes rather than health improvement.
  •  

  • Orlistat is not covered if the member has not tried and failed other weight management interventions that FCHP requires.
  •  

  • Orlistat is denied if there are contraindications or potential drug interactions noted per FCHP's pharmaceutical protocols.
  •  

  • FCHP may not cover Orlistat if prior authorization requirements are not met or if a request for prior authorization was denied based on their criteria.

 

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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 Fallon Community Health Plan (FCHP)

 

Verify Plan Coverage

 

  • Check your current Fallon Community Health Plan (FCHP) benefits to determine if weight-loss medications like Orlistat (Xenical, Alli) are covered. You can do this by reviewing your plan's Summary of Benefits and Coverage (SBC) document.
  •  

  • Log in to your member account on the FCHP website to access your specific plan details and coverage information.

 

Consult with Your Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your weight-loss goals and the potential benefit of using Orlistat (Xenical, Alli).
  •  

  • If your provider deems it necessary, they will provide a prescription for Orlistat and potentially a supporting letter detailing the medical necessity for the medication.

 

Verify Prescription Requirements

 

  • Contact FCHP customer service to confirm if there are any pre-authorization or step therapy requirements for Orlistat coverage. Obtain necessary forms or information from FCHP if pre-authorization is needed.
  •  

  • Provide your healthcare provider with any forms or guidelines required by FCHP to complete the pre-authorization process successfully.

 

Submit a Pre-Authorization Request

 

  • Have your healthcare provider submit a pre-authorization request to FCHP. This includes your prescription, any required forms, and supporting documentation of medical necessity.
  •  

  • Ensure that all submitted information is complete and accurate to avoid delays in the pre-authorization process.
  •  

  • Monitor the status of your pre-authorization request by contacting FCHP or checking their online portal.

 

Appeal if Necessary

 

  • If FCHP denies coverage for Orlistat, review the denial letter for specific reasons and understand the appeal process outlined by FCHP.
  •  

  • Prepare an appeal with the assistance of your healthcare provider, including any additional documentation or evidence supporting the medical necessity of Orlistat.
  •  

  • Submit the appeal to FCHP within the specified timeframe provided in the denial notice. Follow up regularly to track the progress of your appeal.

 

Explore Alternative Options

 

  • If Orlistat remains uncovered, discuss alternative weight-loss medications or treatments with your healthcare provider that may be covered by your FCHP plan.
  •  

  • Consider contacting FCHP to review different health plan options that might better suit your needs and include the desired medication coverage.

 

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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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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.

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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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