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Relistor (methylnaltrexone) — Blue Cross Blue Shield of Texas

Opioid-Induced Constipation (OIC)

Preferred products

  • Symproic (naldemedine)
  • Movantik (naloxegol)

Initial criteria

  • Diagnosis of OIC
  • ONE of the following: (A) requested agent is Relistor (methylnaltrexone) tablet OR Amitiza (lubiprostone) AND patient not receiving methadone AND ONE of the following: chronic non-cancer pain OR chronic pain related to prior cancer or its treatment OR active cancer pain OR (B) request is for Relistor (methylnaltrexone) injection and patient is receiving palliative care AND ONE of the following: patient has advanced illness OR active cancer pain
  • AND patient has chronic use of an opioid agent in the past 30 days
  • AND ONE of the following: (1) BOTH of the following cancer use justifications OR (2) tried and inadequate response to ≥2 standard laxative therapy classes (stimulant, enema, osmotic, stool softener but not including fiber/bulk-forming) OR (3) intolerance/hypersensitivity to ≥2 laxative classes OR (4) FDA labeled contraindication to ALL laxative classes
  • If FDA-labeled indication, ONE of the following: (A) patient’s age within FDA labeling OR (B) support for use in the patient’s age
  • If brand agent with available generic (Amitiza/lubiprostone), ONE of the following: (A) valid cancer exception OR (B) patient currently stable on brand OR (C) tried and inadequate response to generic equivalent OR (D) generic discontinued for efficacy or adverse event OR (E) intolerance/hypersensitivity to generic OR (F) contraindication to generic OR (G) generic expected ineffective or harmful OR (H) generic not in best interest OR (I) tried another drug same class with ineffectiveness/adverse event OR (J) other supported medical reason
  • For agents used in OIC: ONE of the following: patient stable on requested agent OR tried and inadequate response to both Symproic (naldemedine) and Movantik (naloxegol) OR those drugs were discontinued or not tolerated or contraindicated OR expected ineffective or not in best interest OR prior class failure