methylnaltrexone bromide

Generic: Relistor

12 mg/0.6 mL, 150 mg, 8 mg/0.4 mL — Tablet

Also known as: RELISTOR

Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

Blue Cross Blue Shield Federal

3 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 10 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Focus 2026 via Relistor	Tier 2 - Preferred Brand	✓	—	—	PA
BCBS Federal Basic Option 2026 via Relistor	Tier 3 - Non-Preferred Brand	✓	—	—	PA
BCBS Federal Standard Option 2026 via Relistor	Tier 3 - Non-Preferred Brand	✓	—	—	PA

Cigna

1 plan

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 10 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Cigna Plus NC 4-Tier Formulary 2026 via Relistor	Tier 3 - Non-Preferred	✓	—	—	PA

Medicare Part D

37 plans

Source: CMS QHP JSON · Formulary date: Mar 18, 2026 · Checked: 10 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Longevity Health Plan (HMO I-SNP) via Relistor	Tier 1 - Preferred Generic	—	✓	✓ 12 per 30 days	ST \| QL
Provider Partners North Carolina Advantage Plan (HMO I-SNP) via Relistor	Tier 1 - Preferred Generic	—	✓	✓ 12 per 30 days	ST \| QL
Provider Partners North Carolina Essential Plan (HMO I-SNP) via Relistor	Tier 1 - Preferred Generic	—	✓	✓ 12 per 30 days	ST \| QL
Provider Partners North Carolina Community Plan (HMO I-SNP) via Relistor	Tier 1 - Preferred Generic	—	✓	✓ 12 per 30 days	ST \| QL
DEVOTED DUAL PLUS 006 NC (HMO D-SNP) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED CORE 001 NC (HMO) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED GIVEBACK 002 NC (HMO) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED GIVEBACK 012 NC (HMO) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED CHOICE 001 NC (PPO) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED CHOICE GIVEBACK 002 NC (PPO) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED CHOICE 003 NC (PPO) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED CHOICE GIVEBACK 004 NC (PPO) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED CHOICE 005 NC (PPO) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED CHOICE GIVEBACK 006 NC (PPO) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED CHOICE 008 NC (PPO) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED CHOICE GIVEBACK 009 NC (PPO) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
Alignment Health Platinum (HMO) via Relistor	Tier 5 - Specialty	✓	—	✓ 12 per 30 days	PA \| QL
Alignment Health NC Duals (HMO-POS D-SNP) via Relistor	Tier 5 - Specialty	✓	—	✓ 12 per 30 days	PA \| QL
Alignment Health smartHMO (HMO) via Relistor	Tier 5 - Specialty	✓	—	✓ 12 per 30 days	PA \| QL
Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) via Relistor	Tier 5 - Specialty	✓	—	✓ 12 per 30 days	PA \| QL
Alignment Health Platinum Select (HMO) via Relistor	Tier 5 - Specialty	✓	—	✓ 12 per 30 days	PA \| QL
Alignment Health Heart & Diabetes Care (HMO C-SNP) via Relistor	Tier 5 - Specialty	✓	—	✓ 12 per 30 days	PA \| QL
Alignment Health AVA (PPO) via Relistor	Tier 5 - Specialty	✓	—	✓ 12 per 30 days	PA \| QL
HealthTeam Advantage Plan I (PPO) via Relistor	Tier 5 - Specialty	—	✓	✓ 12 per 30 days	ST \| QL
HealthTeam Advantage Plan II (PPO) via Relistor	Tier 5 - Specialty	—	✓	✓ 12 per 30 days	ST \| QL
HealthTeam Advantage Vitality Plan (PPO) via Relistor	Tier 5 - Specialty	—	✓	✓ 12 per 30 days	ST \| QL
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) via Relistor	Tier 5 - Specialty	—	✓	✓ 12 per 30 days	ST \| QL
Troy Medicare (HMO) via Relistor	Tier 5 - Specialty	✓	—	—	PA
DEVOTED DUAL FULL 013 NC (HMO D-SNP) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
DEVOTED DUAL 009 NC (HMO D-SNP) via Relistor	Tier 5 - Specialty	✓	—	✓ 11.2 per 28 days	PA \| QL
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) via Relistor	Tier 5 - Specialty	✓	—	—	PA
AmeriHealth Caritas VIP Care (HMO D-SNP) via Relistor	Tier 5 - Specialty	✓	—	✓ 12 per 30 days	PA \| QL

NC State Health Plan

3 plans

Source: PDF · Formulary date: Apr 1, 2026 · Checked: 10 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 80/20 Plus PPO 2026 via Relistor	Not Covered	—	—	—	None
NC State Health Plan - HDHP 2026 via Relistor	Not Covered	—	—	—	None
NC State Health Plan - 70/30 Standard PPO 2026 via Relistor	Not Covered	—	—	—	None

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jan 5, 2026 · Checked: 10 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
TRICARE Uniform Formulary 2026	Tier 3 - Non-Formulary	✓	—	—	PA