Form 1331, Medicaid Xenical Clinic Prior Authorization

Instructions for Opening a Form

Some forms cannot be viewed in a web browser and must be opened in Adobe Acrobat Reader on your desktop system. Click here for instructions on opening this form.

Documents

Effective Date: 1/2018

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.