Amitiza (lubiprostone) — Blue Cross Blue Shield of Montana

Opioid-Induced Constipation (OIC)

Preferred products

The patient has a diagnosis of opioid-induced constipation (OIC) AND all of the following:
1. ONE of the following:
A. BOTH of the following:
1. ONE of the following:
a. Requested agent is Relistor (methylnaltrexone) tablet OR
b. Requested agent is Amitiza (lubiprostone) AND patient is not receiving a diphenylheptane opioid (e.g., methadone)
2. ONE of the following:
a. Patient has 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 injection AND patient receiving palliative care AND ONE of:
1. Advanced illness OR
2. Pain caused by active cancer
2. Chronic use of opioid agent in past 30 days AND
3. ONE of the following:
1. BOTH of the following:
a. Stage four metastatic cancer diagnosis and appropriate use documented [chart notes required] AND
b. Use consistent with evidence-based literature and FDA approved OR
2. Tried and inadequate response to ≥2 laxative therapy classes (stimulant, enema, osmotic, stool softener, not including fiber/bulking) OR
3. Intolerance/hypersensitivity to ≥2 laxative classes OR
4. FDA labeled contraindication to ALL standard laxative classes
4. If patient has an FDA labeled indication, ONE of:
A. Age within FDA labeling for the indication OR
B. Support exists for using requested agent by age for indication