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.

AmeriHealth Caritas NC

10 plans

Source: CMS QHP JSON · Checked: 14 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Silver Signature + 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 Gold Signature + No Referrals via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Bronze Essential + No Referrals via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Gold Premier + No Referrals via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Bronze Premier + No Referrals via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Bronze Signature + No Referrals via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
AmeriHealth Caritas Next Silver Essential + No Referrals via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL

Blue Cross Blue Shield Federal

3 plans

Source: PDF · Formulary date: Jul 1, 2026 · Checked: 14 hours, 49 minutes ago

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

Cigna

20 plans

Source: PDF · Formulary date: Jan 1, 2026 · Checked: 14 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
Connect Silver RD CMS Standard 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 Gold CMS Standard via Relistor	Tier 4 - Non-Preferred	✓	—	—	PA
Connect Gold RD CMS Standard via Relistor	Tier 4 - Non-Preferred	✓	—	—	PA
Connect Bronze RD CMS Standard via Relistor	Tier 4 - Non-Preferred	✓	—	—	PA
Connect Gold 1500 Indiv Med Deductible via Relistor	Tier 4 - Non-Preferred	✓	—	—	PA
Connect Silver RD 2200 Indiv Med Deductible via Relistor	Tier 4 - Non-Preferred	✓	—	—	PA
Connect myDiabetesCare Silver via Relistor	Tier 4 - Non-Preferred	✓	—	—	PA
Connect Bronze CMS Standard via Relistor	Tier 4 - Non-Preferred	✓	—	—	PA
Connect Silver 3000 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 4400 Indiv Med Deductible via Relistor	Tier 4 - Non-Preferred	✓	—	—	PA
Connect Bronze 7000 HSA Indiv Med Deductible via Relistor	Tier 4 - Non-Preferred	✓	—	—	PA
Connect Silver RD 3500 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 Silver 3500 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 5500 Indiv Med Deductible via Relistor	Tier 4 - Non-Preferred	✓	—	—	PA
Connect myDiabetesCare Bronze via Relistor	Tier 4 - Non-Preferred	✓	—	—	PA

Medicare Part D

37 plans

Source: CMS QHP JSON · Formulary date: Jun 10, 2026 · Checked: 14 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
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 Advantage 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 Community Plan (HMO I-SNP) via Relistor	Tier 1 - Preferred Generic	—	✓	✓ 12 per 30 days	ST \| 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
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 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 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
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: Jul 1, 2026 · Checked: 14 hours, 49 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 - 70/30 Standard PPO 2026 via Relistor	Not Covered	—	—	—	None
NC State Health Plan - 80/20 Plus PPO 2026 via Relistor	Not Covered	—	—	—	None

Oscar Health

28 plans

Source: CMS QHP JSON · Checked: 14 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
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 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
Bronze Simple Diabetes \| with Atrium Health via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Secure \| 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
Silver Simple Diabetes via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Gold Elite Saver Plus via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Simple PCP Saver via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Classic 4700 via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Secure via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Classic via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Elite + PCP Saver Plus via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Gold 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
Bronze Classic Standard \| with Atrium Health via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Gold Classic Standard via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Silver Classic Standard via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
Bronze Classic Standard 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
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

TRICARE

1 plan

Source: Excel (XLSX) · Formulary date: Jun 24, 2026 · Checked: 14 hours, 49 minutes ago

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

UnitedHealthcare

13 plans

Source: PDF · Formulary date: Jun 23, 2026 · Checked: 14 hours, 49 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
UHC Bronze Standard+ Dental + Vision (No Referrals) via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Value ($0 Virtual Urgent Care, 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 Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Bronze Standard (No Referrals) via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Gold Standard (No Referrals) via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Silver Value + ($0 Virtual Urgent Care, 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 Silver Standard (No Referrals) via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL
UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) via Relistor	Tier 4 - Non-Preferred	✓	—	✓	PA \| QL