Relistor (methylnaltrexone bromide) subcutaneous injection — Highmark
OIC with advanced illness or pain caused by active cancer requiring opioid dosage escalation for palliative care
Preferred products
- Movantik
- generic lubiprostone
- Symproic
Initial criteria
- age ≥ 18 years
- diagnosis of OIC (ICD-10: K59.03) due to chronic non-cancer pain OR OIC (ICD-10: K59.03) due to chronic pain related to prior cancer or its treatment and does not require frequent opioid dosage escalation OR OIC (ICD-10: K59.03) and advanced illness or pain caused by active cancer requiring opioid dosage escalation for palliative care
- taking opioid medications for at least one month
- therapeutic failure, contraindication, or intolerance to scheduled dosing of one laxative
- therapeutic failure, contraindication, or intolerance to all of the following plan-preferred products: Movantik, generic lubiprostone, Symproic
Reauthorization criteria
- provider attests that the member has experienced positive clinical response to therapy
Approval duration
12 months