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Relistor (methylnaltrexone) — Blue Cross Blue Shield of Montana

irritable bowel syndrome with constipation (IBS-C)

Initial criteria

  • Target Agent(s) will be approved when ALL of the following are met:
  • 1. ONE of the following:
  • A. The patient has a diagnosis of irritable bowel syndrome with constipation (IBS-C) AND ALL of the following:
  • 1. The patient has had IBS-C symptoms for ≥ 3 months