CurrentBlue Cross Blue Shield - IowaPolicy 05.01.107

Movantik (naloxegol) — Coverage Criteria for Opioid‑Induced Constipation

Defines prior authorization criteria and coverage guidance for Movantik (naloxegol) for treatment of opioid-induced constipation (OIC) in adult patients with chronic non-cancer pain for Wellmark Blue Cross and Blue Shield members.

Policy Summary

PayerBlue Cross Blue Shield - Iowa

PolicyMovantik (naloxegol) — Coverage Criteria for OIC

Policy CodePolicy 05.01.107

Change TypeNo material changes

Effective DateFebruary 23, 2017

Next Review Date

Key ActionObtain prior authorization — Movantik is covered with prior authorization for OIC in adults with chronic non-cancer pain when dosing and criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

1Initial approval criteria group

FDA-approvedIndication status

May 2008Policy creation

Feb 23, 2017Current effective

Coverage Criteria

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Initial Therapy

Covered when ALL of the following are met:

Initial Approval Criteria: Movantik is being prescribed for the treatment of opioid-induced constipation (OIC) in an adult patient with chronic non-cancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation.

FDA-approved indication: OIC in adult patients with chronic non-cancer pain (see package insert).

Dosing and Authorization: Prior authorization is obtained and requested dosing is within limits consistent with FDA-approved labeling, accepted compendia, and evidence-based practice guidelines.

Approvals may be subject to dosing limits per labeling.

This policy’s applicability depends on the member’s contract. Benefit determinations are based on the applicable contract language in effect when services are rendered; exclusions, limitations, or exceptions may apply and individual member benefits must be verified. The policy may not apply to Federal Employee Program (FEP) members; benefits for FEP members are determined by the Federal Employee Program.

Initial Therapy Criteria

Initial therapy — initial approval

Initial approval requires prior authorization and adherence to dosing limits per labeling.

Initial approval: Movantik is prescribed for OIC in an adult with chronic non-cancer pain (including certain prior cancer-related pain without frequent opioid escalation) and dosing is within FDA/compendia limits.

Prior authorization required.

Provider Actions & Requirements

Prior Authorization

Prior Authorization Required

Movantik will be covered with prior authorization when prescribed for the treatment of opioid-induced constipation (OIC) in an adult patient with chronic non-cancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation.

Prior Authorization Required — Movantik prescribed for OIC in an adult with chronic non-cancer pain (including related prior cancer pain without frequent opioid dosage escalation)

Documentation Required

Billing documentation

Use appropriate CPT, HCPCS (alpha-numeric), revenue, and ICD diagnostic codes when reporting services related to Movantik and treatment of OIC. Ensure documentation supports medical necessity and links the prescription to opioid-induced constipation in an adult with chronic non-cancer pain.

Report provider services with applicable CPT, HCPCS, Revenue, and ICD-10 codes
Maintain clinical records that document diagnosis of OIC, opioid use context (chronic non-cancer pain), and rationale for Movantik

Denial Risk

Denial triggers

Denial may be issued if the prescription is not for an adult patient with chronic non-cancer pain OIC (including related prior cancer pain without frequent opioid escalation) or if required authorization criteria and supporting documentation are not met.

Denial triggers — Prescription not for an adult patient with chronic non-cancer pain OIC (including related prior cancer pain without frequent opioid escalation)
Denial triggers — Missing or insufficient documentation to establish diagnosis, opioid use context, or prior authorization approval

Definitions

inv-09: OIC — Opioid-induced constipation definition and context

DefinitionOpioid-induced constipation (OIC) — constipation resulting from opioid therapy addressed by peripherally acting mu-opioid receptor antagonists (e.g., naloxegol).

MechanismNaloxegol is an antagonist of opioid binding at the mu-opioid receptor and, at recommended doses, acts peripherally (gastrointestinal tract) to decrease opioid-related constipation without affecting central analgesia.

FDA‑approved indicationTreatment of OIC in adult patients with chronic non‑cancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation.

Drug classPeripherally-acting mu-opioid receptor antagonist (PAMORA).

Background

Naloxegol (Movantik) is a peripherally acting mu-opioid receptor antagonist indicated to treat opioid-induced constipation (OIC) in adults with chronic non-cancer pain. It works by antagonizing opioid binding at peripheral mu-opioid receptors in the gastrointestinal tract to reduce constipating effects while preserving central analgesia when used at recommended doses. Coverage for Movantik is subject to the benefit and medical necessity determinations described in this policy and any applicable contract limitations.