Get Linzess Prior Authorization Request Form ... - Optumrx

This guide provides a straightforward approach to completing the Linzess Prior Authorization Request Form for submission through OptumRx. Follow the step-by-step instructions to ensure all necessary information is accurately entered for an efficient approval process.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to access the Linzess Prior Authorization Request Form and open it in your preferred editor.
2. Complete the member information section by providing the member's name, date of birth, insurance ID number, and contact details.
3. Fill out the provider information section with the provider's name, NPI number, office phone, fax, and address.
4. In the medication information section, indicate the medication name, strength, and whether this is a new start by checking the appropriate box.
5. Input the directions for use and dosage form required for the medication.
6. Select the appropriate diagnosis from the clinical information section and provide any additional diagnosis or ICD-9/10 codes if necessary.
7. List any medications the member has had failure, contraindications, or intolerance to from the provided options.
8. State the quantity requested per day and reason for exceeding plan limitations, selecting the appropriate justification.
9. Add any comments, further diagnoses, symptoms, or additional information that may assist in the review.
10. Review all filled sections to ensure accuracy. Once completed, save changes, download, print, or share the form as needed.

Begin filling out the Linzess Prior Authorization Request Form online today to streamline the approval process.