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Get Optumrx & Linzess Prior Authorization Request Form 2019-2025
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How to fill out the OPTUMRx & Linzess Prior Authorization Request Form online
The OPTUMRx & Linzess Prior Authorization Request Form is essential for obtaining necessary approvals for specific medications. This guide will provide a clear, step-by-step approach to filling out the form online, ensuring that users submit accurate and complete information.
Follow the steps to successfully complete the form.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Begin by filling out the member information section. Enter the member's name, insurance ID number, date of birth, and contact details.
- Next, provide the provider information. Include the provider's name, national provider identifier (NPI) number, office phone, and address details.
- Under the medication information section, specify the medication name, strength, and indicate if you are requesting a brand medication or continuing therapy.
- Complete the directions for use and dosage form fields.
- In the clinical information section, select the relevant diagnosis from the list provided, and include the ICD-10 code if applicable.
- Indicate any medications the patient has previously tried and failed or has contraindications to. This may include polyethylene glycol, , and for requests, also Linzess, Movantik, or Symproic.
- If this is a reauthorization request, confirm if there is documentation of a positive clinical response to therapy.
- For quantity limit requests, specify the quantity requested per day and provide reasons for exceeding plan limitations.
- Lastly, include any other comments or additional relevant information that may assist in the review process.
- After completing all fields, make sure to review your entries for accuracy before saving changes, downloading, or printing the form for submission.
Complete your OPTUMRx & Linzess Prior Authorization Request Form online today.
Submitting a prior authorization to Optum Rx is straightforward. You can fill out the OPTUMRx & Linzess Prior Authorization Request Form, ensuring that all required fields are completed accurately. Once filled out, submit the form online or via fax as directed by Optum. If you have questions during the process, do not hesitate to reach out to their support team for assistance.
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