Does SummaCare Cover Orlistat (Xenical, Alli)

Discover SummaCare's coverage for Orlistat, why it might be denied, steps to gain coverage, costs without insurance, and get answers to FAQs in this guide.
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Does SummaCare Cover Orlistat (Xenical, Alli)?

 

  • SummaCare typically provides coverage for Orlistat (Xenical, Alli) if it's deemed medically necessary for weight management.
  •  

  • Coverage may depend on a demonstrated need for treatment of obesity or related conditions, often verified by a healthcare provider.
  •  

  • Patients may need to meet specific criteria, such as a Body Mass Index (BMI) over a certain threshold or other health risk factors related to obesity.
  •  

  • Pre-authorization or documentation from a healthcare provider may be required to justify the necessity of the prescription.
  •  

  • Coverage specifics can vary based on the patient's plan and benefits; contacting SummaCare directly for detailed information is recommended.

 

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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.

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 SummaCare

 

Understanding SummaCare Coverage for Orlistat

 

  • Before starting, confirm if Orlistat (Xenical, Alli) is included in SummaCare's formulary by visiting their official website or contacting customer service.
  •  

  • Ensure you meet the medical criteria for Orlistat reimbursement, such as BMI requirements or having certain medical conditions.

 

Connect with a Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your weight loss goals and the possibility of a prescription for Orlistat.
  •  

  • Obtain a prescription from your provider if they agree that Orlistat is suitable for you based on your health needs.

 

Verify Your Prescription Coverage

 

  • Contact SummaCare member services using the phone number on your insurance card to verify that your specific plan covers Orlistat.
  •  

  • Ask about any required prior authorizations, step therapy, or specific pharmacies you must use to obtain coverage.

 

Submit Required Documentation

 

  • If prior authorization is required, work with your healthcare provider to gather any necessary documentation, including medical records and the prescription itself.
  •  

  • Submit all required information to SummaCare according to their procedures, which might involve online submissions or mailing forms.

 

Understand Potential Costs

 

  • Inquire about your copay or coinsurance for Orlistat under your SummaCare plan to avoid unexpected costs at the pharmacy.
  •  

  • Check if there are any manufacturer coupons or programs that might help reduce the cost of Orlistat if coverage is limited.

 

Fill Your Prescription

 

  • Once coverage confirmation is obtained and any authorizations are approved, take your prescription to an in-network pharmacy.
  •  

  • Ensure the pharmacy processes your prescription through your SummaCare insurance to apply the benefit and reduce your out-of-pocket expenses.

 

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FAQs

Does SummaCare Cover Orlistat (Xenical, Alli)

Discover SummaCare's coverage for Orlistat, why it might be denied, steps to gain coverage, costs without insurance, and get answers to FAQs in this guide.
Curex allergy drops unboxing

Is Orlistat (Xenical, Alli) Covered by SummaCare

 

Does SummaCare Cover Orlistat (Xenical, Alli)?

 

  • SummaCare typically provides coverage for Orlistat (Xenical, Alli) if it's deemed medically necessary for weight management.
  •  

  • Coverage may depend on a demonstrated need for treatment of obesity or related conditions, often verified by a healthcare provider.
  •  

  • Patients may need to meet specific criteria, such as a Body Mass Index (BMI) over a certain threshold or other health risk factors related to obesity.
  •  

  • Pre-authorization or documentation from a healthcare provider may be required to justify the necessity of the prescription.
  •  

  • Coverage specifics can vary based on the patient's plan and benefits; contacting SummaCare directly for detailed information is recommended.

 

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

 

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

 

  • Member must be 18 years of age or older to qualify for Orlistat coverage.
  •  

  • The medication is prescribed as part of a comprehensive weight loss program that includes a reduced-calorie diet, increased physical activity, and behavioral modification.
  •  

  • Body Mass Index (BMI) requirement:
    • BMI is 30 kg/m² or higher, indicating obesity.
    • Alternatively, BMI is 27 kg/m² or higher with at least one weight-related comorbidity (e.g., hypertension, type 2 diabetes, dyslipidemia).

     

  • Member must have tried and failed to achieve a clinically significant weight loss with diet and exercise alone, documented by at least six months of physician-supervised weight loss efforts.
  •  

  • Documentation of the member's initial BMI and updated BMI measurements, along with other relevant clinical information, should be provided by the healthcare provider.
  •  

  • Regular follow-up appointments must be planned to monitor the efficacy and safety of Orlistat therapy, with continued use depending on achieving at least a 5% reduction in baseline body weight within the first 12 weeks of treatment.
  •  

  • Counseling on potential gastrointestinal side effects and the importance of adherence to a reduced-fat diet is required.
  •  

  • Particular attention and approval must be given for individuals with a history of organ transplant, malabsorption syndrome, or cholestasis, as these may be contraindications for Orlistat use.
  •  

 

Why SummaCare Might Deny Orlistat (Xenical, Alli) Coverage

 

Reasons for Denial of Orlistat Coverage by SummaCare

 

  • Prescription is not medically necessary: Orlistat may be denied if it is determined that the drug is not medically necessary according to evidence or clinical guidelines.
  •  

  • Failure to meet weight management criteria: Coverage might be denied if the patient does not meet specific criteria related to weight management, such as Body Mass Index (BMI) thresholds or documented history of weight-related health issues.
  •  

  • Inadequate documentation: Denial can occur if there is insufficient medical documentation showing prior efforts at weight management or other relevant medical conditions.
  •  

  • Lack of prior authorization: SummaCare may require prior authorization before approving Orlistat coverage, and failing to obtain this could lead to denial.
  •  

  • Use for non-approved conditions: Orlistat may be denied if used for conditions not approved by the FDA or other regulatory bodies.
  •  

  • Non-compliance with plan policies: Failure to comply with specific plan policies or guidelines regarding weight loss medications could result in denial of 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.

 

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 SummaCare

 

Understanding SummaCare Coverage for Orlistat

 

  • Before starting, confirm if Orlistat (Xenical, Alli) is included in SummaCare's formulary by visiting their official website or contacting customer service.
  •  

  • Ensure you meet the medical criteria for Orlistat reimbursement, such as BMI requirements or having certain medical conditions.

 

Connect with a Healthcare Provider

 

  • Schedule an appointment with your healthcare provider to discuss your weight loss goals and the possibility of a prescription for Orlistat.
  •  

  • Obtain a prescription from your provider if they agree that Orlistat is suitable for you based on your health needs.

 

Verify Your Prescription Coverage

 

  • Contact SummaCare member services using the phone number on your insurance card to verify that your specific plan covers Orlistat.
  •  

  • Ask about any required prior authorizations, step therapy, or specific pharmacies you must use to obtain coverage.

 

Submit Required Documentation

 

  • If prior authorization is required, work with your healthcare provider to gather any necessary documentation, including medical records and the prescription itself.
  •  

  • Submit all required information to SummaCare according to their procedures, which might involve online submissions or mailing forms.

 

Understand Potential Costs

 

  • Inquire about your copay or coinsurance for Orlistat under your SummaCare plan to avoid unexpected costs at the pharmacy.
  •  

  • Check if there are any manufacturer coupons or programs that might help reduce the cost of Orlistat if coverage is limited.

 

Fill Your Prescription

 

  • Once coverage confirmation is obtained and any authorizations are approved, take your prescription to an in-network pharmacy.
  •  

  • Ensure the pharmacy processes your prescription through your SummaCare insurance to apply the benefit and reduce your out-of-pocket expenses.

 

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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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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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