Skip to content
The Policy VaultThe Policy Vault

Relistor (methylnaltrexone) — Blue Cross Blue Shield of Oklahoma

opioid-induced constipation (OIC)

Preferred products

  • Symproic (naldemedine)
  • Movantik (naloxegol)

Initial criteria

  • Patient has diagnosis of opioid-induced constipation (OIC)
  • ONE of the following: BOTH of the following: requested agent is Relistor (methylnaltrexone) tablet OR Amitiza (lubiprostone) AND patient not receiving diphenylheptane opioid (e.g., methadone) AND ONE of the following: patient has chronic non-cancer pain OR chronic pain related to prior cancer or its treatment OR active cancer pain OR requested agent is Relistor (methylnaltrexone) injection AND patient receiving palliative care AND patient has advanced illness OR pain caused by active cancer
  • Patient has chronic use of an opioid agent in past 30 days
  • ONE of the following: BOTH of the following: prescriber statement or documentation of stage four advanced metastatic cancer and use consistent with best practices and FDA approval OR patient has tried and had inadequate response to ≥2 standard laxative therapy classes (stimulant, enema, osmotic, or stool softener but not fiber/bulking) OR intolerance/hypersensitivity to ≥2 laxative classes OR FDA labeled contraindication to ALL standard laxative therapy classes
  • If FDA labeled indication, one of: patient’s age within FDA labeling or supported for use for patient’s age
  • If brand with generic equivalent, one of: prescriber statement of metastatic cancer and best practices OR patient stable on brand OR tried and failed generic equivalent OR discontinued generic due to AE or lack of efficacy OR intolerance, hypersensitivity, or contraindication to generic OR generic expected ineffective or harmful OR generic not in best interest OR tried another in class and discontinued due to adverse outcome OR support for brand use
  • For use in OIC: ONE of the following: prescriber statement or documentation of metastatic cancer and best practices OR patient currently stable on requested agent OR patient tried and had inadequate response to Symproic (naldemedine) and Movantik (naloxegol) OR both discontinued for inefficacy or AE OR intolerance/hypersensitivity to both Symproic and Movantik OR FDA labeled contraindication to both that not expected with requested agent OR Symproic and Movantik expected ineffective, harmful, or not in best interest OR prior drug in same class failed