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Relistor (methylnaltrexone) — Blue Cross Blue Shield of Illinois

irritable bowel syndrome with constipation (IBS-C)

Preferred products

  • Trulance (plecanatide)
  • Linzess (linaclotide)
  • Symproic (naldemedine)
  • Movantik (naloxegol)

Initial criteria

  • For IBS-C: ONE of the following: (A) The requested agent is Ibsrela (tenapanor) OR (B) The requested agent is Amitiza (lubiprostone) AND ONE of the following: (1) The patient's sex is female OR (2) The requested agent is medically appropriate for the patient's sex and the intended diagnosis AND ONE of the following: (A) BOTH of the following: (1) ONE of the following: (A) Stage four advanced, metastatic cancer diagnosis and use to treat cancer OR (B) Documentation of stage four advanced, metastatic cancer and treatment of related associated condition [chart notes required] AND (2) Use is consistent with best practices, evidence-based, and FDA approved OR (B) Tried and inadequate response to ≥2 standard laxative therapy classes (e.g., bulk forming, stimulant, enema, osmotic, stool softener) OR (C) Intolerance or hypersensitivity to ≥2 standard laxative therapy classes OR (D) FDA labeled contraindication to ALL standard laxative therapy classes.
  • For CIC: Diagnosis of chronic idiopathic constipation (CIC) AND ALL of the following: (1) Symptoms ≥3 months AND (2) Requested agent is Amitiza (lubiprostone) or Motegrity (prucalopride) AND ONE of the following: (A) BOTH of the following: (1) ONE of the following: (A) Stage four advanced, metastatic cancer diagnosis and treatment of cancer OR (B) Documentation of stage four advanced metastatic cancer and treatment of related associated condition [chart notes required] AND (2) Use is consistent with best practices, evidence-based, and FDA approved OR (B) Tried and inadequate response to ≥2 standard laxative therapy classes OR (C) Intolerance or hypersensitivity to ≥2 standard laxative therapy classes OR (D) FDA labeled contraindication to ALL standard laxative therapy classes.
  • For OIC: Diagnosis of opioid-induced constipation (OIC) AND ALL of the following: (1) ONE of the following: (A) BOTH of the following: (1) The requested agent is Relistor (methylnaltrexone) tablet OR Amitiza (lubiprostone) AND patient not receiving diphenylheptane opioid (e.g., methadone) AND (2) ONE of the following: (A) Chronic non-cancer pain OR (B) Chronic pain related to prior cancer or its treatment OR (C) Active cancer pain OR (B) Request is for Relistor (methylnaltrexone) injection, and patient receiving palliative care with ONE of the following: (1) Advanced illness OR (2) Pain caused by active cancer) AND (2) Chronic use of opioid in past 30 days AND (3) ONE of the following: (1) BOTH of the following: (A) Stage four advanced, metastatic cancer diagnosis and treatment of cancer OR documentation of associated condition [chart notes required] AND (B) Use consistent with best practices, evidence-based, and FDA approved OR (2) Tried and inadequate response to ≥2 standard laxative therapy classes (excluding fiber/bulking agents) OR (3) Intolerance or hypersensitivity to ≥2 standard laxative classes OR (4) FDA labeled contraindication to ALL standard laxative classes) AND (4) If FDA labeled indication: ONE of the following: (A) Age within FDA labeling for indication OR (B) Supported for age and indication).