& Linzess Prior Authorization Request Form ... - OptumRx 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by filling out the Member Information section. Enter the member's name, insurance ID number, and date of birth. Ensure all fields are completed accurately.
3. Next, provide the Provider Information. Input the provider's name, NPI number, office phone, and address details.
4. In the Medication Information section, specify the medication name and strength. Indicate if this is a continuation of therapy and provide dosage form and directions for use.
5. Complete the Clinical Information section by selecting the requested drug and diagnosis. Answer any additional questions regarding medication history and reauthorization as applicable.
6. Review all entered information for accuracy before submitting. Once complete, you can easily save or print your form directly from our platform.

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