Currentmedical mutual - ohioPolicy N/A

Mu-opioid receptor antagonists for opioid-induced constipation (Movantik, Symproic)

Defines prior authorization and coverage criteria for naloxegol (Movantik) and naldemedine (Symproic) for treatment of opioid-induced constipation in adults with chronic non-cancer pain under the payer's pharmacy benefit.

Policy Summary

Payermedical mutual - ohio

PolicyMu-opioid receptor antagonists for opioid-induced constipation (Movantik, Symproic)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateMay 22, 2026

Key ActionPrior authorization is recommended for pharmacy benefit coverage of Movantik and Symproic when patients meet the policy's coverage criteria.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2impacted drugs listed

365initial approval duration

365extended approval duration

05/22/2025last revised

Coverage and Authorization Criteria

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Approval Durations

Approval durations:

Initial approval duration: Initial Approval: 365 days365 days

Extended approval duration: Extended Approval: 365 days365 days

Reauthorization requires response to therapy unless otherwise noted

Coverage is provided only for the specific circumstances described in the Recommended Authorization Criteria for opioid‑induced constipation (OIC). Coverage is not recommended for circumstances not listed in those criteria. The drugs Movantik (naloxegol) and Symproic (naldemedine) have not been shown to be effective, or have limited/preliminary data, or potential safety concerns for other uses; such conditions are not generally approved.

Requests for indications or clinical situations outside the listed criteria will be reviewed on a case‑by‑case basis; criteria will be updated as new published data become available. Providers should supply supporting clinical documentation when requesting coverage for atypical or off‑label uses.

Initial Therapy Criteria

Initial approval is provided when coverage criteria are met.

Age and diagnosis: Patient is >=18 years and has documented chronic non-cancer pain with OIC and does not require frequent opioid dose escalation.

Initial approval duration: 365 days

Continuation and Reauthorization Criteria

Continuation/Extended Approval

Continuation requires documented response to therapy for reauthorization unless noted otherwise.

Continuation requirement: Reauthorization requires documented response to therapy unless otherwise noted.

Continuation/extended approval duration: 365 days

Provider Actions and Prior Authorization Requirements

Prior Authorization

Prior authorization recommended

Prior authorization is recommended for pharmacy benefit coverage of Movantik (naloxegol) and Symproic (naldemedine); approval is recommended when criteria are met.

Pharmacy benefit prior authorization is recommended for Movantik (naloxegol) and Symproic (naldemedine).
Approval is recommended for members who meet the conditions of coverage in the Criteria and Initial/Extended Approval for the provided diagnosis.
Requests for uses not listed in this policy will be reviewed on a case-by-case basis for evidence of efficacy and medical necessity.

Note

Case-by-case review for off-label uses

Requests for uses not listed in this policy will be reviewed on a case-by-case basis for evidence of efficacy and medical necessity.

Documentation Required

Documentation required on request

The Company may request additional documentation as part of its coverage determination process. Documentation requested may include patient records, test results, and/or credentials of the provider ordering or performing the service. Additional documentation supporting medical necessity must be made available upon request.

Patient medical records relevant to the request
Relevant test results (e.g., diagnostic tests, lab reports)
Provider credentials or documentation of the ordering/prescribing provider
Evidence of response to therapy for reauthorization requests when continuation is allowed

Denial Risk

Denial risk conditions

The Company may deny reimbursement when the drug or services were not medically necessary, investigational or experimental, not within the member's benefit scope, or otherwise excluded. The Company reserves the right to modify or interpret this policy at its sole discretion.

Denial may occur if the drug or services were not medically necessary
Denial may occur if the drug or services were investigational or experimental
Denial may occur if the drug or services are not within the member benefit
Denial may occur for inappropriate or excessive billing patterns

Definitions and Eligibility

Opioid Induced Constipation (OIC) — eligibility

Population ageAdults 18 years of age or older

Diagnosis requirementDocumented opioid‑induced constipation (OIC) in the setting of chronic non‑cancer pain

Cancer‑related painIncludes chronic pain related to prior cancer or its treatment

Exclusion — active/frequently escalating opioid therapyExcludes patients who require frequent (e.g., weekly) opioid dose escalation

Applicable medicationsPolicy applies to peripherally acting mu‑opioid receptor antagonists (Movantik [naloxegol], Symproic [naldemedine]) for OIC

Background

Naloxegol (Movantik) and naldemedine (Symproic) are peripherally acting mu‑opioid receptor antagonists that target opioid‑induced constipation by blocking peripheral opioid effects in the gastrointestinal tract. They are indicated for treatment of OIC in adults with chronic non‑cancer pain, including pain related to prior cancer or its treatment, when frequent opioid dose escalation is not required.

These agents act on peripheral mu‑opioid receptors to relieve constipation symptoms without substantially affecting central analgesia at recommended doses. Clinical use and coverage are limited to the scenarios described in the policy because effectiveness and safety data are limited or preliminary for other conditions.