CurrentUnitedHealthcarePolicy N/A

Relistor (methylnaltrexone) prior authorization — tablets and syringe/vial coverage criteria

Prior authorization form and criteria for coverage of Relistor (tablets and injection) for opioid-induced constipation in UnitedHealthcare beneficiaries; applies to prescribers requesting pharmacy benefit coverage.

Policy Summary

PayerUnitedHealthcare

PolicyRelistor (methylnaltrexone) prior authorization — tablets and syringe/vial coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete and sign the prior authorization form including the clinical checklist and submit required documentation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Formulations assessed

>=18Minimum age

>=4 wkMin opioid duration

Amitiza & MovantikRequired prior trial

Improvement documentedRe-auth requirement

Coverage Criteria for Relistor (methylnaltrexone)

Relistor tablets — Initial authorization criteria

Covered when ALL of the following are met

Relistor tablets initial criteria: 1) Diagnosis of opioid-induced constipation with chronic non-cancer pain (including chronic pain related to prior cancer or its treatment that does not require frequent opioid dosage escalation); 2) Age 18 years or older; 3) No known or suspected mechanical gastrointestinal obstruction; 4) Received opioids for at least 4 weeks; 5) Trial and failure of both Amitiza (lubiprostone) AND Movantik (naloxegol) or documented contraindication/intolerance to both; 6) Prescriber signature on the form

All checklist items on the tablet form must be answered affirmatively or justified

Relistor syringe/vial — Initial authorization criteria

Covered when ALL of the following are met

Relistor injection initial criteria: 1) Diagnosis of opioid-induced constipation for chronic non-cancer pain OR opioid-induced constipation with advanced illness/active cancer requiring opioid dosage escalation for palliative care (form includes checkbox to distinguish these indications); 2) Age 18 years or older; 3) No known or suspected mechanical gastrointestinal obstruction; 4) Received opioids for at least 4 weeks; 5) Trial and failure of both Amitiza (lubiprostone) AND Movantik (naloxegol) or documented contraindication/intolerance to both; 6) Prescriber signature on the form

Policy Summary

PayerUnitedHealthcare

PolicyRelistor (methylnaltrexone) prior authorization — tablets and syringe/vial coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionPrescriber must complete and sign the prior authorization form including the clinical checklist and submit required documentation.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coding, Age, and Opioid Exposure Requirements

Minimum opioid exposure

Minimum opioid exposureReceived opioids for at least 4 weeks

Evidence sourceChecklist items on both tablet and syringe/vial forms require opioid use >=4 weeks

Re-authorization noteRe-authorizations require documentation of symptom improvement from baseline in addition to continued opioid exposure criteria as applicable

Minimum beneficiary age

Minimum beneficiary ageAge 18 years or older

Form requirementBoth tablet and syringe/vial forms include an explicit checkbox confirming beneficiary is age 18 or older

Potential denial triggerMissing documentation of age >=18 may trigger denial

Opioid-induced constipation

DefinitionConstipation attributed to opioid therapy in patients receiving chronic opioid treatment; forms ask providers to indicate whether the condition is related to chronic non-cancer pain or advanced illness/active cancer (syringe/vial).

Form applicationProviders must identify opioid-induced constipation on the Relistor tablet or syringe/vial form as part of initial authorization criteria

Contraindication checkForms require that known or suspected mechanical gastrointestinal obstruction be ruled out before approval

Prescriber Requirements and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for Relistor. Complete and submit the prescriber PA form; the prescriber signature and date are mandatory. Use the Pharmacy PA Call Center (1-855-258-1593) for questions.

Prescriber Signature: required on form
Pharmacy PA Call Center: 1-855-258-1593
Include drug name, strength, quantity per 30 days, and length of therapy selection

Step Therapy

Step Therapy / Prior Trial

Step therapy must be documented. The member must have tried and failed Amitiza (lubiprostone) AND Movantik (naloxegol) unless there is a documented contraindication or intolerance to one or both agents.

Required prior trial: Amitiza AND Movantik — both must be tried and failed unless contraindicated/intolerant
Document dates and duration of each prior therapy trial
For syringe/vial (advanced illness) and tablet indications, same step therapy applies

Documentation Required

Required Documentation

Provide completed PA form fields and supporting clinical documentation: diagnosis, age, opioid use duration, prior trial/failure details or contraindications, and symptom improvement for re-authorizations. The prescriber signature and date are required.

Form fields to complete: drug name, strength, quantity per 30 days, length of therapy (initial or re-authorization selection)
Clinical checklist items: diagnosis (OIC with chronic non-cancer pain or advanced illness/palliative indication where applicable), age ≥18, presence/absence of mechanical GI obstruction, opioid use ≥4 weeks
Prior therapy documentation: dates, agents tried (Amitiza and Movantik), reasons for failure (inefficacy or intolerance) or documented contraindication(s) with explanation
Re-authorization: documentation of symptom improvement from baseline
Mandatory prescriber signature and date

Denial Risk

Potential Denial Triggers

Incomplete or missing information may result in denial. Ensure age, opioid duration, prior trial/failure or contraindication details, and prescriber signature are all present.

Denial risks: missing age or beneficiary not ≥18 documented
Denial risks: opioid therapy duration <4 weeks or not documented
Denial risks: no documentation of trials and failures of Amitiza AND Movantik, or missing contraindication/intolerance explanation
Denial risks: missing prescriber signature or date on PA form
Denial risks: absent documentation of symptom improvement for re-authorizations

Initial Therapy Authorization Requirements

Initial therapy — Initial authorization requirements

Initial authorization requirements

Initial therapy: Age >=18; diagnosis of opioid-induced constipation as specified for the requested formulation (tablets: chronic non-cancer pain; syringe/vial: chronic non-cancer pain or advanced illness/active cancer requiring opioid escalation for palliative care); no known or suspected mechanical gastrointestinal obstruction; received opioids for at least 4 weeks; trial and failure of Amitiza AND Movantik or documented contraindication/intolerance to both; prescriber completes and signs the prior authorization form; select initial authorization duration on the form

Form lists selectable initial authorization durations (prescriber to indicate)

Required prior agents	Exception / alternative
Amitiza (lubiprostone)	Not covered as an alternative — Relistor requires prior trial and failure of both Amitiza AND Movantik unless there is a documented contraindication or intolerance to both agents
Movantik (naloxegol)	If beneficiary has documented contraindication or intolerance to BOTH Amitiza and Movantik, the prior trial requirement is waived per form documentation

Background

Relistor (methylnaltrexone) is a peripherally acting mu‑opioid receptor antagonist indicated for opioid‑induced constipation. The prior authorization forms cover both oral Relistor tablets and the injectable Relistor syringe/vial; the syringe/vial form distinguishes use for chronic non‑cancer pain versus opioid‑induced constipation in patients with advanced illness or active cancer who require opioid dose escalation for palliative care.

The forms require confirmation of key clinical criteria before authorizing therapy, including beneficiary age 18 years or older, documentation that the beneficiary has received opioids for at least 4 weeks, absence of mechanical gastrointestinal obstruction, and either prior trial and failure of both Amitiza (lubiprostone) and Movantik (naloxegol) or documented contraindication/intolerance to both agents. Prescriber signature on the form is mandatory, and re‑authorization additionally requires documentation of symptom improvement from baseline.

OpenPayer