Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
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For prescribing providers to request prior authorization for the drug Xenical® (orlistat).
When to Prepare
- This form is only used for people enrolled in Medicaid fee-for-service.
- Requests must be signed and submitted by the prescribing provider.Please complete all requested information or document why information is not available.
- Staff sends the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax or mail.
Vendor Drug Program (MC-2250)
Texas Health and Human Services
4900 North Lamar Blvd.
Austin, TX 78751
- Questions about this form should be directed to the Vendor Drug Program at 800-435-4165.