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Relistor — Blue Cross Blue Shield of Alabama

pediatric functional constipation

Initial criteria

  • Diagnosis of IBS-C AND symptoms ≥ 3 months AND ONE of the following: requested agent is Trulance (plecanatide), Linzess (linaclotide), or Ibsrela (tenapanor); OR requested agent is Amitiza (lubiprostone) AND ONE of the following: patient’s sex is female OR requested agent is medically appropriate for the patient’s sex and indication
  • Diagnosis of CIC AND symptoms ≥ 3 months AND requested agent is Amitiza (lubiprostone), Linzess (linaclotide), Motegrity (prucalopride), or Trulance (plecanatide)
  • Diagnosis of OIC AND ONE of the following: requested agent is Symproic (naldemedine), Movantik (naloxegol), or Relistor (methylnaltrexone) tablet; OR requested agent is Amitiza (lubiprostone) and the patient is not currently receiving methadone; OR requested agent is Linzess (linaclotide) and the patient has active cancer pain; OR request is for Relistor (methylnaltrexone) injection and patient is receiving palliative care AND has advanced illness or pain caused by active cancer; AND patient has chronic use of opioid agent in past 30 days
  • Diagnosis of pediatric functional constipation
  • For each diagnosis above, ONE of the following: has tried and had inadequate response to TWO standard laxative therapy classes (bulk-forming, stimulant, enema, osmotic, or stool softener); OR tried and had inadequate response to ONE laxative class and intolerance/hypersensitivity to ONE laxative class; OR intolerance/hypersensitivity to TWO laxative classes; OR FDA-labeled contraindication to ALL laxative classes
  • If FDA-labeled indication, patient's age is within labeling OR there is support for use at patient's age
  • If request is for brand with generic equivalent (Amitiza/lubiprostone, Motegrity/prucalopride): intolerance or hypersensitivity or contraindication to generic not expected with brand OR support for brand use
  • ONE of the following: requested indication does not require preferred agent(s); OR request is for a preferred target agent; OR patient has tried and had inadequate response to ALL preferred agents; OR intolerance/hypersensitivity or contraindication to ALL preferred agents not expected with requested; OR support for non-preferred over preferred
  • Requested agent will not be used in combination with another constipation agent (Amitiza/lubiprostone, Ibsrela, Linzess, Motegrity/prucalopride, Movantik, Relistor, Symproic, Trulance)
  • Patient has no FDA-labeled contraindications to requested agent

Reauthorization criteria

  • Patient has been previously approved for requested agent through plan’s prior authorization process
  • If FDA-labeled indication, patient's age is within labeling OR supported for use at patient’s age
  • If brand with generic equivalent (Amitiza/lubiprostone, Motegrity/prucalopride): intolerance, hypersensitivity, or contraindication to generic not expected with brand OR support for brand
  • Patient has had clinical benefit with requested agent
  • Patient will not be using requested agent in combination with another constipation agent (Amitiza/lubiprostone, Ibsrela, Linzess, Motegrity/prucalopride, Movantik, Relistor, Symproic, Trulance)
  • Patient does not have any FDA-labeled contraindications to requested agent

Approval duration

12 months