Relistor
Generic: methylnaltrexone bromide
12 MG/0.6 ML — Prefilled Syringe
PERIPHERAL OPIOID RECEPTOR ANTAGONISTS
Also known as:
methylnaltrexone bromide
RELISTOR SOLN 12MG/0.6ML; SOSY 8MG/0.4ML, 12MG/0.6ML; TABS 150MG
Relistor 8 Mg/0.4 Ml Syringe
Relistor 12 Mg/0.6 Ml Syringe
Relistor 12 Mg/0.6 Ml Vial
RELISTOR SOLN 12MG/0.6ML; SOSY
Relistor Oral Tablet
Methylnaltrexone bromide
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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.
AmeriHealth Caritas NC
10 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| AmeriHealth Caritas Next Silver Off-Marketplace High + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Signature + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Essential + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Premier + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Off-Marketplace Low + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Essential + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
Blue Cross Blue Shield Federal
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| BCBS Federal Focus 2026 | Tier 2 - Preferred Brand | ✓ | — | — | PA |
| BCBS Federal Standard Option 2026 | Tier 3 - Non-Preferred Brand | ✓ | — | — | PA |
| BCBS Federal Basic Option 2026 | Tier 3 - Non-Preferred Brand | ✓ | — | — | PA |
Cigna
20 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Connect Silver RD CMS Standard | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Silver CMS Standard | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Bronze 6500 Indiv Med Deductible | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Gold CMS Standard | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Gold RD CMS Standard | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Bronze RD CMS Standard | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Gold 1500 Indiv Med Deductible | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Silver RD 2200 Indiv Med Deductible | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect myDiabetesCare Silver | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Bronze CMS Standard | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Silver 3000 Indiv Med Deductible | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Silver RD 5000 Indiv Med Deductible | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Silver 4400 Indiv Med Deductible | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Bronze 7000 HSA Indiv Med Deductible | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Silver RD 3500 Indiv Med Deductible | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Bronze RD 5000 Indiv Med Deductible | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Silver 3500 Indiv Med Deductible | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Bronze RD 6000 Indiv Med Deductible | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect Bronze 5500 Indiv Med Deductible | Tier 4 - Non-Preferred | ✓ | — | — | PA |
| Connect myDiabetesCare Bronze | Tier 4 - Non-Preferred | ✓ | — | — | PA |
Medicare Part D
37 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | ✓ | ✓ 12 per 30 days | ST | QL |
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | ✓ | ✓ 12 per 30 days | ST | QL |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | ✓ | ✓ 12 per 30 days | ST | QL |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | ✓ | ✓ 12 per 30 days | ST | QL |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED CORE 001 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED CHOICE 003 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED CHOICE 008 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 11.2 per 28 days | PA | QL |
| Alignment Health Platinum (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 12 per 30 days | PA | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 12 per 30 days | PA | QL |
| Alignment Health smartHMO (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 12 per 30 days | PA | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 12 per 30 days | PA | QL |
| Alignment Health Platinum Select (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 12 per 30 days | PA | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 12 per 30 days | PA | QL |
| Alignment Health AVA (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 12 per 30 days | PA | QL |
| HealthTeam Advantage Plan I (PPO) | Tier 5 - Specialty | — | ✓ | ✓ 12 per 30 days | ST | QL |
| HealthTeam Advantage Plan II (PPO) | Tier 5 - Specialty | — | ✓ | ✓ 12 per 30 days | ST | QL |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 5 - Specialty | — | ✓ | ✓ 12 per 30 days | ST | QL |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 5 - Specialty | — | ✓ | ✓ 12 per 30 days | ST | QL |
| Troy Medicare (HMO) | Tier 5 - Specialty | ✓ | — | — | PA |
| Troy Medicare for Dual-eligible Beneficiaries (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | — | PA |
| AmeriHealth Caritas VIP Care (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 12 per 30 days | PA | QL |
NC State Health Plan
3 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| NC State Health Plan - HDHP 2026 | Not Covered | — | — | — | None |
| NC State Health Plan - 70/30 Standard PPO 2026 | Not Covered | — | — | — | None |
| NC State Health Plan - 80/20 Plus PPO 2026 | Not Covered | — | — | — | None |
Oscar Health
28 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Silver Classic | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Silver Simple PCP Saver | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Gold Elite Saver Plus | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Bronze Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Bronze Simple Chronic Care CKM | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Bronze Simple Diabetes | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Secure | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Silver Simple Chronic Care CKM | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Silver Simple Women's Health with Menopause Benefits | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AIAN Cost Share | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AIAN Cost Share | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Silver Simple Diabetes | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Gold Elite Saver Plus | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Silver Simple PCP Saver | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Bronze Classic 4700 | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Secure | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Silver Classic | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Gold Classic Standard | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Silver Classic Standard | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Bronze Classic Standard | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Gold Classic Standard | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Silver Classic Standard | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Bronze Classic Standard | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Silver Simple Breathe Easy with Enhanced COPD Benefits | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Bronze Classic 4700 | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| Bronze Elite + PCP Saver Plus | with Atrium Health | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
TRICARE
1 planUnitedHealthcare
13 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| UHC Bronze Standard+ Dental + Vision (No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Essential ($0 Virtual Urgent Care, No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Value ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Advantage + ($0 Virtual Urgent Care, $3 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Advantage ($0 Virtual Urgent Care, $1 Tier 2 Rx, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Standard (No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Standard (No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Value + ($0 Virtual Urgent Care, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Advantage ($0 Virtual Urgent Care, $3 Tier 2 Rx, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Silver Standard (No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Gold Advantage + ($0 Virtual Urgent Care, $1 Tier 2 Rx, Dental + Vision, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| UHC Bronze Copay Focus $0 Indiv Med Ded ($0 Virtual Urgent Care, No Referrals) | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |