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Movantik (naloxegol) — Blue Cross Blue Shield of Kansas

Opioid-induced constipation (OIC)

Initial criteria

  • Diagnosis of IBS-C AND symptoms ≥ 3 months AND ONE of the following: (A) Requested agent is Trulance, Linzess, or Ibsrela OR (B) Requested agent is Amitiza AND (1) Patient's sex is female OR (2) Requested agent is medically appropriate for patient's sex and intended diagnosis AND ONE of the following: (A) Tried and had inadequate response to 2 standard laxative therapy classes (bulk-forming, stimulant, enema, osmotic, stool softener) OR (B) Tried and had inadequate response to 1 standard laxative therapy class AND has intolerance/hypersensitivity to another class OR (C) Has intolerance/hypersensitivity to 2 laxative therapy classes OR (D) Has FDA labeled contraindication to ALL standard laxative therapy classes.
  • Diagnosis of CIC AND symptoms ≥ 3 months AND requested agent is Amitiza, Linzess, Motegrity, or Trulance AND ONE of the following: (A) Tried and had inadequate response to 2 standard laxative therapy classes (bulk-forming, stimulant, enema, osmotic, stool softener) OR (B) Tried and had inadequate response to 1 class and intolerance/hypersensitivity to 1 class OR (C) Intolerance or hypersensitivity to 2 classes OR (D) Has FDA labeled contraindication to ALL standard laxative therapy classes.
  • Diagnosis of OIC AND ALL of the following: (1) ONE of the following: (A) Requested agent is Symproic, Movantik, or Relistor tablet OR (B) Requested agent is Amitiza AND not receiving diphenylheptane opioid (e.g., methadone) OR (C) Requested agent is Linzess AND patient has active cancer pain OR (D) Request is for Relistor injection AND patient receiving palliative care AND (1) Advanced illness OR (2) Pain caused by active cancer; AND (2) Chronic opioid use within past 30 days; AND (3) ONE of the following: (A) Inadequate response to 2 standard laxative therapy classes (stimulant, enema, osmotic, or stool softener, excluding fiber/bulking agents) OR (B) Inadequate response to 1 class AND intolerance/hypersensitivity to 1 class OR (C) Intolerance/hypersensitivity to 2 classes OR (D) FDA labeled contraindication to ALL standard laxative therapy classes.
  • Diagnosis of pediatric functional constipation AND ONE of the following: (A) Inadequate response to at least 2 standard laxative therapy classes OR (B) Inadequate response to 1 class AND intolerance/hypersensitivity to 1 class OR (C) Intolerance/hypersensitivity to 2 classes OR (D) FDA labeled contraindication to ALL standard laxative therapy classes.
  • If agent has FDA labeled indication: patient's age within labeling OR supported use for patient's age for indication.
  • If brand agent with generic equivalent (Amitiza/lubiprostone, Motegrity/prucalopride): ONE of the following: (A) Intolerance/hypersensitivity to generic equivalent not expected with brand OR (B) FDA labeled contraindication to generic equivalent not expected with brand OR (C) Clinical support for brand use over generic.
  • ONE of the following regarding preferred agents: (A) Indication does not require preferred agent(s) OR (B) Request is for preferred target agent OR (C) Inadequate response to ALL preferred agents for indication OR (D) Intolerance/hypersensitivity to ALL preferred agents not expected with requested agent OR (E) FDA labeled contraindication to ALL preferred agents not expected with requested agent OR (F) Clinical support for non-preferred agent over preferred agent.
  • Requested agent NOT used in combination with another constipation agent (Amitiza, Ibsrela, Linzess, Motegrity, Movantik, Relistor, Symproic, Trulance).
  • No FDA labeled contraindication to requested agent.

Reauthorization criteria

  • Previously approved for requested agent through plan’s Prior Authorization process.
  • If agent has FDA labeled indication: patient's age within labeling OR supported use for patient's age for indication.
  • If brand agent with generic equivalent (Amitiza/lubiprostone, Motegrity/prucalopride): ONE of the following: (A) Intolerance/hypersensitivity to generic equivalent not expected with brand OR (B) FDA labeled contraindication to generic equivalent not expected with brand OR (C) Clinical support for brand use over generic.
  • Has had clinical benefit with requested agent.
  • Requested agent NOT used in combination with another constipation agent (Amitiza, Ibsrela, Linzess, Motegrity, Movantik, Relistor, Symproic, Trulance).
  • No FDA labeled contraindication to requested agent.

Approval duration

12 months