CurrentCignaPolicy IP0401

Opioid-Induced Constipation

Cigna drug coverage policy defining prior authorization and medical necessity criteria for Movantik (naloxegol), Relistor (methylnaltrexone tablets and injection), and Symproic (naldemedine) for treatment of opioid-induced constipation (OIC) in adults, including criteria differences for advanced illness/active cancer and plan-specific preferred product requirements.

Policy Summary

PayerCigna

PolicyOpioid-Induced Constipation

Policy CodePolicy IP0401

Change TypeMaterial revisions to criteria and preferred product requirements

Effective DateJan 1, 2026

Next Review Date

Key ActionObtain prior authorization for Movantik, Relistor (tablets and injection), and Symproic and ensure required prior-therapy trials and attestation of opioid dose escalation status per plan-specific criteria.

POLICY UPDATE CHANGES

Added preferred product requirements for Relistor tablets.

Updated criterion requiring the patient to not be requiring frequent opioid dosage escalation from documentation to attestation and removed laxative failure duration requirement.

For Relistor injection advanced-illness indication, added requirement for documentation of chronic opioid use.

Added preferred product requirements for Relistor tablets, Relistor injection, and Symproic tablets for Individual and Family Plans.

Annual revision May 1, 2024 reported 'No criteria changes.'

3Drugs covered

12 months

Typical approval duration

18+Age requirement (years)

Coverage Summary

coverage_stance: covered_with_criteria (prior authorization required for Movantik, Relistor [tablets and injection], and Symproic).

scope_summary: Cigna drug coverage policy defining prior authorization and medical necessity criteria for Movantik (naloxegol), Relistor (methylnaltrexone tablets and injection), and Symproic (naldemedine) for treatment of opioid-induced constipation (OIC) in adults, with plan-specific preferred product/step requirements and an advanced-illness/active cancer indication for Relistor injection.

stats: Typical approval duration: 12 months; Age requirement: 18+; Drugs covered: Movantik, Relistor (tablets and injection), Symproic.

Policy metadata

Policy NumberIP0401

Effective Date1/1/2026

Last Review1/1/2025

Typical approval duration12 months

Age requirement (years)18+

Policy StatusCURRENT

Initial Therapy Criteria (FDA-Approved Indications)

Movantik and Symproic - FDA-Approved Indication (OIC)

Approve for 12 months if the patient meets ALL of the following criteria:

ALL of the following

Diagnosis: Opioid-induced constipation (OIC).
Patient is 18 years or older.
Patient has chronic opioid use.
Patient does not require frequent (i.e. weekly) opioid dosage escalation.
Attestation of not requiring frequent escalation is acceptable (per revision).

Plan-Specific Prior Therapy / Step Requirements

Employer Plans - Relistor tablets

Additional step requirement for Employer Plans:

Required prior therapies

List (both required)
- Movantik (naloxegol)
- Symproic (naldemedine)

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Continuation Therapy Criteria

criteria_trees: Approvals are provided for 12 months. For each criteria tree: "Approve for 12 months if the patient meets ALL of the following criteria:" — the same criteria used for initial approval are used for renewal/continuation where applicable.

Not Medically Necessary / Exclusions

Not Medically Necessary

Excluded uses

Movantik, Relistor (tablets and injection), and Symproic for any use other than the specified OIC indications are not medically necessary.

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title

ref:5

title:Not Medically Necessary

ref":"b4_0"

Applicable Codes

Drugs referenced (by generic and brand)NDC|mixedCovered

naloxegol	Movantik (naloxegol tablets - Valinor)
methylnaltrexone	Relistor (methylnaltrexone bromide tablets and injection - Salix/Progenics)
naldemedine	Symproic (naldemedine tablets - Shionogi/BioDelivery Sciences International)
lubiprostone	lubiprostone (generics, Amitiza) - used in step edits for some plans

Clinical Evidence & Guidelines

Evidence summary: Guideline recommendations include the American Gastroenterological Association (AGA, 2019) recommendation to use Symproic or Movantik for laxative-refractory OIC and a suggestion for Relistor (tablets or injection). The American Academy of Pain Medicine (AAPM, 2017) also notes efficacy of peripherally-acting mu-opioid receptor antagonists including Movantik and Relistor. Prescribing information references: Movantik (Mar 2023), Relistor (Apr 2020), and Symproic (Jul 2021).

Background

Therapies and indications: Movantik (naloxegol), Relistor (methylnaltrexone tablets and injection), and Symproic (naldemedine) are peripherally-acting mu-opioid receptor antagonists indicated for opioid-induced constipation (OIC) in adults with chronic non-cancer pain. Relistor injection additionally is indicated for OIC in adults with advanced illness or active cancer who require opioid dosage escalation for palliative care. Policy notes that these agents act peripherally in the gastrointestinal tract to decrease opioid-induced constipation.

Guideline support and preference: The AGA (2019) recommends Symproic or Movantik for laxative-refractory OIC and suggests Relistor; the AAPM (2017) supports efficacy of Movantik and Relistor. The policy includes plan-specific preferred product or step requirements (e.g., employer and Individual & Family Plan step edits) that influence product selection.

Definitions:

Chronic opioid use: Policy requires the patient to have chronic opioid use (term stated by the policy; no additional numeric definition provided).

Frequent opioid dosage escalation: Defined in the policy as "i.e., weekly" escalation; patients must not require weekly escalation (attestation from the prescriber is acceptable per revision).

Revision History

1/1/2025material

Added preferred product requirements for Relistor tablets.

1/1/2025material

Updated criterion requiring the patient to not be requiring frequent opioid dosage escalation from documentation to attestation and removed laxative failure duration requirement for Relistor tablets, Relistor injection, Movantik, and Symproic.

9/1/2024material

For Relistor injection advanced-illness/active cancer indication, added requirement for documentation of chronic opioid use and clarified prescriber attestation for opioid dosage escalation for palliative care.

Policy Summary

PayerCigna

PolicyOpioid-Induced Constipation

Policy CodePolicy IP0401

Change TypeMaterial revisions to criteria and preferred product requirements

Effective DateJan 1, 2026

Next Review Date

On This Page

Preferred product criteria is met for the product(s) as listed in the policy tables.

title:Movantik and Symproic - FDA-Approved Indication (OIC)

Relistor tablets - FDA-Approved Indication (OIC)

Approve for 12 months if the patient meets ALL of the following criteria:

ALL of the following

Diagnosis: Opioid-induced constipation (OIC).
Patient is 18 years or older.
Patient has chronic opioid use.
Patient does not require frequent (i.e. weekly) opioid dosage escalation.
Attestation acceptable.
Preferred product criteria is met for the product(s) as listed in the policy tables.

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title

ref:1

title:Relistor tablets - FDA-Approved Indication (OIC)

ref":"b1_1"

Relistor injection - FDA-Approved Indications

Approve for 12 months if the patient meets ALL of the following criteria for OIC generally or for advanced-illness indication:

General OIC indication

Diagnosis: Opioid-induced constipation (OIC).
Patient is 18 years or older.
Patient has chronic opioid use.
Attestation acceptable.
Patient does not require frequent (i.e. weekly) opioid dosage escalation.
Preferred product criteria is met for the product(s) as listed in the policy tables.

Advanced illness / active cancer indication (Relistor injection only)

Diagnosis: Opioid-induced constipation (OIC) in individuals with advanced illness or pain caused by active cancer.
Patient is 18 years or older.
Patient has chronic opioid use.
Patient requires opioid dosage escalation for palliative care (prescriber indicates patient requires escalation for palliative care).

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title

ref:2

title:Relistor injection - FDA-Approved Indications

ref":"b1_2"

title:Employer Plans - Relistor tablets

Individual and Family Plans - Relistor tablets and Symproic tablets and Relistor injection

Additional step requirements for Individual and Family Plans:

Relistor tablets (Individual & Family Plans)

List (both required)
- Movantik (naloxegol)
- lubiprostone (generics, Amitiza)

Relistor subcutaneous injection (Individual & Family Plans)

List (both required)
- Movantik (naloxegol)
- lubiprostone (generics, Amitiza)

Symproic tablets (Individual & Family Plans)

List (both required)
- Movantik (naloxegol)
- lubiprostone (generics, Amitiza)

ref

title

ref:4

title:Individual and Family Plans - Relistor tablets and Symproic tablets and Relistor injection

ref":"b2_1"

Prior Authorization

Prior Authorization required

Prior Authorization is required for Movantik, Relistor (tablets and injection), and Symproic; approvals are typically provided for 12 months.

Typical approval duration: 12 months
Affected products: Movantik (naloxegol); Relistor (methylnaltrexone) tablets and injection; Symproic (naldemedine)

Step Therapy

Required prior therapies for Relistor (plan dependent)

Plan-dependent step requirements for Relistor tablets differ by line of business. For Employer Plans, Relistor tablets require trials of both Movantik and Symproic. For Individual & Family Plans, Relistor tablets require trials of both Movantik and lubiprostone; Relistor subcutaneous injection and Symproic tablets also require trials of both Movantik and lubiprostone under Individual & Family Plans.

Employer Plans — Relistor tablets: trial of Movantik and Symproic (both required)
Individual & Family Plans — Relistor tablets: trial of Movantik and lubiprostone (both required)
Individual & Family Plans — Relistor subcutaneous injection: trial of Movantik and lubiprostone (both required)
Individual & Family Plans — Symproic tablets: trial of Movantik and lubiprostone (both required)

Documentation Required

Attestation of opioid dose escalation status

The policy revision changed the requirement for confirming the patient does not require frequent (i.e., weekly) opioid dosage escalation from documentation to attestation; attestation from the prescriber is acceptable.

Specific criterion: "Patient does not require frequent (i.e. weekly) opioid dosage escalation" — attestation from the prescriber is acceptable

Denial Risk

Denial for non-covered use

Claims for Movantik, Relistor (tablets and injection), and Symproic billed for indications other than the specified opioid-induced constipation (OIC) indications will be denied as not medically necessary.

Products subject to denial for non-covered use: Movantik; Relistor (tablets and injection); Symproic

date not clearly specifiedmaterial

Added preferred product requirements for Relistor tablets, Relistor injection, and Symproic tablets for Individual and Family Plans; updated formatting.

5/1/2024non-material

Annual revision reported 'No criteria changes.'