Relistor Subcutaneous
12 MG/0.6ML — Solution
Gastrointestinal Agents, Other
Also known as:
Relistor Subcutaneous Solution
Relistor Subcutaneous Solution Prefilled Syringe
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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 Essential + 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 Bronze Essential + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Gold Signature + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| 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 Bronze Premier + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Gold Premier + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Silver Premier + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
| AmeriHealth Caritas Next Bronze Signature + No Referrals | Tier 4 - Non-Preferred | ✓ | — | ✓ | PA | QL |
Medicare Part D
37 plans| Plan | Tier | Prior Auth | Step Therapy | Quantity Limit | Restrictions |
|---|---|---|---|---|---|
| Provider Partners North Carolina Advantage Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | ✓ | ✓ 18 per 30 days | ST | QL |
| Provider Partners North Carolina Community Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | ✓ | ✓ 18 per 30 days | ST | QL |
| Provider Partners North Carolina Essential Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | ✓ | ✓ 18 per 30 days | ST | QL |
| Longevity Health Plan (HMO I-SNP) | Tier 1 - Preferred Generic | — | ✓ | ✓ 18 per 30 days | ST | QL |
| DEVOTED CHOICE 003 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 004 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED CHOICE 005 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 006 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED CHOICE 008 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 009 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| Alignment Health Platinum (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Alignment Health NC Duals (HMO-POS D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Alignment Health smartHMO (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Alignment Health Heart & Diabetes NCPlus (HMO-POS C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Alignment Health Platinum Select (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Alignment Health Heart & Diabetes Care (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| Alignment Health AVA (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HealthTeam Advantage Plan I (PPO) | Tier 5 - Specialty | — | ✓ | ✓ 18 per 30 days | ST | QL |
| HealthTeam Advantage Vitality Plan (PPO) | Tier 5 - Specialty | — | ✓ | ✓ 18 per 30 days | ST | QL |
| HealthTeam Advantage Diabetes & Heart Care (HMO C-SNP) | Tier 5 - Specialty | — | ✓ | ✓ 18 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 | ✓ | — | ✓ 18 per 30 days | PA | QL |
| HealthTeam Advantage Plan II (PPO) | Tier 5 - Specialty | — | ✓ | ✓ 18 per 30 days | ST | QL |
| DEVOTED DUAL FULL 013 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 014 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED C-SNP PLUS 015 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 016 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 017 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED C-SNP PREMIUM 018 NC (HMO C-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED DUAL PLUS 006 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED DUAL 009 NC (HMO D-SNP) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED CORE 001 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED GIVEBACK 002 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED GIVEBACK 012 NC (HMO) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED CHOICE 001 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |
| DEVOTED CHOICE GIVEBACK 002 NC (PPO) | Tier 5 - Specialty | ✓ | — | ✓ 16.8 per 28 days | PA | QL |