| Anthem Blue Cross (HMO, PPO, EPO) |
| Relistor (methylnaltrexone) |
| Drugs for Overdose or Poisoning : Drugs for Overdose or Poisoning |
- Prior Authorization: Opioid Induced Constipation:
PA Applies
- Opioid Induced Constipation:
Failed or intolerant to increase in dietary fiber or conventional laxative therapy: Yes
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Patient must have chronic use of opioids: No
Patient must not be using methadone: No
- Quantity Limit: 1 syringe per 1 day(s).
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