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.
- This addendum must accompany the Texas Department of Insurance Standard Prior Authorization Form (PDF).
- 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.