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Effective Date: 
1/2018

Documents

Instructions

Updated: 1/2018

 

Purpose

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.

 

Detailed Instructions

  • Staff sends the form to the Medicaid-enrolled pharmacy, who then forwards the completed form by fax or mail.

 

Transmittal

  • Fax:

512-491-1962

  • Mail:

Vendor Drug Program (MC-2250)
Texas Health and Human Services
4900 North Lamar Blvd.
Austin, TX 78751

 

Questions

  • Questions about this form should be directed to the Vendor Drug Program at 800-435-4165.