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PRIOR AUTHORIZATION REQUEST FORM
Jul 1, 2024 If the request is for Amitiza, Motegritiy or Trulance, has the member had an adequate trial and failure of Linzess? ☐. ☐. Please provide
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Motegrity (prucalopride)
Jul 1, 2019 The FDA approved Motegrity based on data from 6 individual trials. Clinical trials were varied in geographic region and timeframe, with some
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Amitiza (lubiprostone) or Linzess (linaclotide)
Amitiza is indicated for the treatment of opioid-induced constipation (OIC) in adults with chronic non- cancer pain. Limitations of Use: Effectiveness of
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