methylnaltrexone bromide

Generic: Relistor

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

GASTROINTESTINAL-2 AGENTS

Also known as: RELISTOR
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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.
Source: CMS QHP JSON  ·  Formulary date: Sep 22, 2026  ·  Checked: 15 hours, 23 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace Low + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Essential + Two Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Premier + No Referrals
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Enhanced + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Off-Marketplace High + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Silver Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Signature + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Bronze Essential + Three Free PCP Visits + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AmeriHealth Caritas Next Gold Copay Focus + $0 Deductible + Free PCP + Free 24/7 Preferred Provider PCP/Urgent Virtual Care + No Referrals
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 23 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
Source: PDF  ·  Formulary date: Oct 7, 2026  ·  Checked: 15 hours, 23 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Connect myDiabetesCare Silver
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Gold 1500 Indiv Med Deductible
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Bronze RD 5000 Indiv Med Deductible
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Bronze RD 6000 Indiv Med Deductible
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Bronze RD CMS Standard
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Silver RD 3500 Indiv Med Deductible
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Silver RD 5000 Indiv Med Deductible
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Silver RD CMS Standard
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Silver RD 2200 Indiv Med Deductible
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Gold RD CMS Standard
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Bronze 7000 HSA Indiv Med Deductible
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Bronze CMS Standard
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Gold CMS Standard
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect myDiabetesCare Bronze
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Silver 5000 Indiv Med Deductible
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Silver 3600 Indiv Med Deductible
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Silver 3000 Indiv Med Deductible
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Silver CMS Standard
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Bronze 6500 Indiv Med Deductible
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Connect Bronze 5500 Indiv Med Deductible
via Relistor 		Tier 4 - Non-Preferred ✓ — — PA
Source: CMS QHP JSON  ·  Formulary date: Sep 16, 2026  ·  Checked: 15 hours, 23 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Provider Partners North Carolina Community Plan (HMO I-SNP)
via Relistor 		Tier 1 - Preferred Generic — ✓ ✓ 12 per 30 days ST | QL
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
DEVOTED CHOICE 005 NC (PPO)
via Relistor 		Tier 5 - Specialty ✓ — ✓ 11.2 per 28 days PA | QL
Troy Medicare (HMO)
via Relistor 		Tier 5 - Specialty ✓ — — PA
Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP)
via Relistor 		Tier 5 - Specialty ✓ — — PA
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
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 DUAL PLUS 006 NC (HMO D-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
DEVOTED GIVEBACK 012 NC (HMO)
via Relistor 		Tier 5 - Specialty ✓ — ✓ 11.2 per 28 days PA | QL
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
Alignment Health AVA (PPO)
via Relistor 		Tier 5 - Specialty ✓ — ✓ 12 per 30 days PA | QL
AmeriHealth Caritas VIP Care (HMO D-SNP)
via Relistor 		Tier 5 - Specialty ✓ — ✓ 12 per 30 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
HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP)
via Relistor 		Tier 5 - Specialty — ✓ ✓ 12 per 30 days ST | 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
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
Source: PDF  ·  Formulary date: Oct 1, 2026  ·  Checked: 15 hours, 23 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
NC State Health Plan - HDHP 2026
via Relistor 		Not Covered — — — None
NC State Health Plan - 80/20 Plus PPO 2026
via Relistor 		Not Covered — — — None
NC State Health Plan - 70/30 Standard PPO 2026
via Relistor 		Not Covered — — — None
Source: CMS QHP JSON  ·  Checked: 15 hours, 23 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
Bronze Classic Standard
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic Standard | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Standard | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Classic Standard | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Chronic Care CKM | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Secure | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic 4700 | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Diabetes | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple PCP Saver | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Elite Saver Plus | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Simple Diabetes | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Chronic Care CKM | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Women's Health with Menopause Benefits | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AIAN Cost Share
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
AIAN Cost Share | with Atrium Health
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Elite + PCP Saver Plus
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Secure
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Bronze Classic 4700
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple PCP Saver
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Elite Saver Plus
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Simple Diabetes
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Silver Classic Standard
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Gold Classic Standard
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
Source: Excel (XLSX)  ·  Formulary date: Jul 31, 2026  ·  Checked: 15 hours, 23 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
TRICARE Uniform Formulary 2026 Tier 3 - Non-Formulary ✓ — — PA
Source: PDF  ·  Formulary date: Sep 23, 2026  ·  Checked: 15 hours, 23 minutes ago
Plan Tier Prior Auth Step Therapy Quantity Limit Restrictions
UHC Bronze Essential ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Standard ($5 Tier 2 Rx, $0 Insulin, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Value ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Standard+ (HSA, $0 Insulin, Dental + Vision, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, $0 Insulin, Dental + Vision, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Copay Focus+ $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Copay Focus+ $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, Dental + Vision, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Value+ ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Copay Focus $0 Ded ($0 Virtual Urgent Care, $5 Tier 2 Rx, $0 Insulin, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, HSA, $0 Insulin, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Bronze Standard (HSA, $0 Insulin, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Gold Advantage+ ($0 Virtual Urgent Care, $1 Tier 2 Rx, $0 Insulin, Dental + Vision, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
UHC Silver Standard ($8 Tier 2 Rx, $0 Insulin, No Referrals)
via Relistor 		Tier 4 - Non-Preferred ✓ — ✓ PA | QL
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