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Start with prior authorization (PA) for RELISTOR.

For the best results, follow these steps:

  • 1.

  • Provide patient and insurance information – include patient’s mobile number

    • Include patient’s mobile number
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  • 2.

  • Include prescriber information

    • Practice name, your name, NPI #, DEA/License #
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  • 3.

  • Provide accurate information, including:

    • Patient age, diagnosis, dosing
    • The following ICD-10 code can be considered for OIC* K59.03: Drug-induced constipation
    • Previous therapies tried and failed
    • Rationale for prescribing RELISTOR

Did you know that you can complete a PA in 3 easy steps with CoverMyMeds?

Be sure the below
information is included and
accurate on RELISTOR PAs

Age

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  • 18 years or older2

Suggested ICD-10-CM 
CODE FOR OIC*

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  • K59.033:

    Drug-induced
    constipation

Previous Therapies Tried and Failed

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  • Duration of therapy

    (eg, OTC laxatives

    and other relevant
    prescription therapies)

Approved Dosing for OIC

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  • RELISTOR Tablets:

    450 mg, three 150-mg tablets once daily (90 tablets/prescription)2

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  • RELISTOR Subcutaneous Injection: 12 mg subcutaneously, once daily, as directed 
(28 prefilled syringes)2

Please refer to full Prescribing Information for dose adjustments in patients with renal or hepatic impairment.

DEA, Drug Enforcement Administration; ICD-10-CM, International Classification of Diseases, Tenth Revision, Clinical Modification; NPI, National Provider Identifier;

OIC, opioid-induced constipation.

*The ICD-10 code and all other patient access–related information are provided for informational purposes only. It is the treating physician’s responsibility to determine the proper diagnosis, treatment, and applicable ICD-10-CM code. Salix Pharmaceuticals does not guarantee coverage or reimbursement for the product.

COMPREHENSIVE SUPPORT TO
HELP YOUR PATIENTS ACCESS
AND SAVE ON RELISTOR

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Sample Letter of Medical Necessity for RELISTOR

For payers who may require a letter of Medical Necessity to process and cover RELISTOR claims.

Download
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Sample Medical Exception Request for RELISTOR

File exceptions or prior authorization requests for Medicare Part D coverage.

Download
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Sample Appeal Letter for RELISTOR

Appeal a denied claim for RELISTOR.

Download
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Tier Exemption Request for RELISTOR

Request a formulary exception to allow coverage for RELISTOR.

Download
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RELISTOR Medical Exceptions & Patient Support Services Guide

A guide to steps required, requested documentation, and correct forms.

Download
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RELISTOR Navigating Coverage Brochure

Being proactive with PAs may lead to higher approval rates.1 Follow this helpful guide to request coverage of RELISTOR.

Download
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Resource Cost Flashcard

A quick reference card for you and your office staff summarizing the cost of RELISTOR to patients, and resources available to help with that cost.

Download

LIS/M3P Flashcard

A quick reference to 
the medication reimbursement support available through the Low-Income Subsidy (LIS)/Medicare Prescription Payment Plan (M3P) pathways for Medicare patients.

Download
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Common PA Questions Sheet

A tool that outlines questions commonly asked during the PA process, to support you and your office staff in planning for a PA application.

Download

ASPN Pharmacies streamline the prescription process to help your patients get access to RELISTOR.

Three easy steps to use ASPN Pharmacies:

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  • Access
 Search for ASPN Pharmacies in your EMR and submit your patient’s Rx.

  • new

  • Communication
 Upon receiving your prescription, ASPN Pharmacies will communicate and coordinate with the patient and their insurance to get the prescription filled.

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  • Visibility
 Access prescription status, prior authorizations (PAs), and other relevant data on the ASPN Pharmacies Prescriber Portal anytime.

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COMMON REASONS FOR PA DENIAL
and how to avoid them

Double-check PA, fill in missing information, and resubmit.

Confirm Dosing

  • RELISTOR tablets: RELISTOR 450 mg, three 150 mg tablets once daily (90 tablets/prescription)
  • RELISTOR Subcutaneous Injection: RELISTOR 12 mg subcutaneously, once daily, as directed (28 prefilled syringes)
  • Please refer to full Prescribing Information for dose adjustments in patients with renal or hepatic impairment

Confirm ICD-10-CM code and resubmit

The following ICD-10 codes can be considered for OIC:‡

  • K59.03: Drug-induced constipation

‡The ICD-10-CM code and all other patient access-related information are provided for informational purposes only. It is the treating physician’s responsibility to determine the proper diagnosis, treatment, and applicable ICD-10-CM code. Salix Pharmaceuticals does not guarantee coverage or reimbursement for the product.

Include information on why RELISTOR is necessary and appropriate for the patient.

Ensure documentation of OTC laxative trial and failure or trial and failure of any other appropriate step therapies, if applicable.

Confirm coverage; Medicare excludes certain drugs

  • RELISTOR is not in a Medicare excluded category

Understand your local state laws
regarding patient access
Access Step Therapy Laws by State

Learn more

References: 1. Data on File. PA Approval. Salix Pharmaceuticals, Bridgewater, NJ.  2. RELISTOR [prescribing information]. Bridgewater, NJ: Salix Pharmaceuticals. 3. ICD-10. Centers for Medicare & Medicaid Services: https://www.cms.gov/medicare/coding-billing/icd-10-codes. Updated April 1, 2026. Accessed April 9, 2026. 

RELISTOR® is for adult patients with opioid-induced constipation (OIC) and chronic non-cancer pain.

INDICATIONS

  • RELISTOR® (methylnaltrexone bromide) is an opioid antagonist. RELISTOR tablets and RELISTOR injection are indicated for the treatment of opioid-induced constipation (OIC) in adults with chronic non-cancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation.
  • RELISTOR injection is also indicated for the treatment of OIC in adults with advanced illness or pain caused by active cancer who require opioid dosage escalation for palliative care.

IMPORTANT SAFETY INFORMATION

  • RELISTOR tablets and injection are contraindicated in patients with known or suspected mechanical gastrointestinal obstruction and patients at increased risk of recurrent obstruction, due to the potential for gastrointestinal perforation.
  • Cases of gastrointestinal perforation have been reported in adult patients with opioid-induced constipation and advanced illness with conditions that may be associated with localized or diffuse reduction of structural integrity in the wall of the gastrointestinal tract (e.g., peptic ulcer disease, Ogilvie’s syndrome, diverticular disease, infiltrative gastrointestinal tract malignancies or peritoneal metastases). Take into account the overall risk-benefit profile when using RELISTOR in patients with these conditions or other conditions which might result in impaired integrity of the gastrointestinal tract wall (e.g., Crohn’s disease). Monitor for the development of severe, persistent, or worsening abdominal pain; discontinue RELISTOR in patients who develop this symptom.
  • If severe or persistent diarrhea occurs during treatment, advise patients to discontinue therapy with RELISTOR and consult their healthcare provider.
  • Symptoms consistent with opioid withdrawal, including hyperhidrosis, chills, diarrhea, abdominal pain, anxiety, and yawning have occurred in patients treated with RELISTOR. Patients having disruptions to the blood-brain barrier may be at increased risk for opioid withdrawal and/or reduced analgesia and should be monitored for adequacy of analgesia and symptoms of opioid withdrawal.
  • Avoid concomitant use of RELISTOR with other opioid antagonists because of the potential for additive effects of opioid receptor antagonism and increased risk of opioid withdrawal.
  • The use of RELISTOR during pregnancy may precipitate opioid withdrawal in a fetus due to the immature fetal blood-brain barrier and should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Because of the potential for serious adverse reactions, including opioid withdrawal, in breastfed infants, advise women that breastfeeding is not recommended during treatment with RELISTOR. In nursing mothers, a decision should be made to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.
  • A dosage reduction of RELISTOR tablets and RELISTOR injection is recommended in patients with moderate and severe renal impairment (creatinine clearance less than 60 mL/minute as estimated by Cockcroft-Gault). No dosage adjustment of RELISTOR tablets or RELISTOR injection is needed in patients with mild renal impairment.
  • A dosage reduction of RELISTOR tablets is recommended in patients with moderate (Child-Pugh Class B) or severe (Child-Pugh Class C) hepatic impairment. No dosage adjustment of RELISTOR tablets is needed in patients with mild hepatic impairment (Child-Pugh Class A). No dosage adjustment of RELISTOR injection is needed for patients with mild or moderate hepatic impairment. In patients with severe hepatic impairment, monitor for methylnaltrexone-related adverse reactions and dose adjust per Prescribing Information as may be indicated.
  • In the clinical studies, the most common adverse reactions were:

OIC in adult patients with chronic non-cancer pain

  • RELISTOR tablets (≥ 2% of RELISTOR patients and at a greater incidence than placebo): abdominal pain (14%), diarrhea (5%), headache (4%), abdominal distention (4%), vomiting (3%), hyperhidrosis (3%), anxiety (2%), muscle spasms (2%), rhinorrhea (2%), and chills (2%).
  • RELISTOR injection (≥ 1% of RELISTOR patients and at a greater incidence than placebo): abdominal pain (21%), nausea (9%), diarrhea (6%), hyperhidrosis (6%), hot flush (3%), tremor (1%), and chills (1%).

OIC in adult patients with advanced illness

  • RELISTOR injection (≥ 5% of RELISTOR patients and at a greater incidence than placebo): abdominal pain (29%), flatulence (13%), nausea (12%), dizziness (7%), and diarrhea (6%).

To report SUSPECTED ADVERSE REACTIONS, contact Salix Pharmaceuticals at 1-800-321-4576 or FDA at  1-800-FDA-1088 or www.fda.gov/medwatch.

Please click here for full Prescribing Information for RELISTOR tablets and RELISTOR injection.

INDICATIONS

  • RELISTOR® (methylnaltrexone bromide) is an opioid antagonist. RELISTOR tablets and RELISTOR injection are indicated for the treatment of opioid-induced constipation (OIC) in adults with chronic non-cancer pain, including patients with chronic pain related to prior cancer or its treatment who do not require frequent (e.g., weekly) opioid dosage escalation.
  • RELISTOR injection is also indicated for the treatment of OIC in adults with advanced illness or pain caused by active cancer who require opioid dosage escalation for palliative care.

IMPORTANT SAFETY INFORMATION

  • RELISTOR tablets and injection are contraindicated in patients with known or suspected mechanical gastrointestinal obstruction and patients at increased risk of recurrent obstruction, due to the potential for gastrointestinal perforation.
  • Cases of gastrointestinal perforation have been reported in adult patients with opioid-induced constipation and advanced illness with conditions that may be associated with localized or diffuse reduction of structural integrity in the wall of the gastrointestinal tract (e.g., peptic ulcer disease, Ogilvie’s syndrome, diverticular disease, infiltrative gastrointestinal tract malignancies or peritoneal metastases). Take into account the overall risk-benefit profile when using RELISTOR in patients with these conditions or other conditions which might result in impaired integrity of the gastrointestinal tract wall (e.g., Crohn’s disease). Monitor for the development of severe, persistent, or worsening abdominal pain; discontinue RELISTOR in patients who develop this symptom.
  • If severe or persistent diarrhea occurs during treatment, advise patients to discontinue therapy with RELISTOR and consult their healthcare provider.
  • Symptoms consistent with opioid withdrawal, including hyperhidrosis, chills, diarrhea, abdominal pain, anxiety, and yawning have occurred in patients treated with RELISTOR. Patients having disruptions to the blood-brain barrier may be at increased risk for opioid withdrawal and/or reduced analgesia and should be monitored for adequacy of analgesia and symptoms of opioid withdrawal.
  • Avoid concomitant use of RELISTOR with other opioid antagonists because of the potential for additive effects of opioid receptor antagonism and increased risk of opioid withdrawal.
  • The use of RELISTOR during pregnancy may precipitate opioid withdrawal in a fetus due to the immature fetal blood-brain barrier and should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Because of the potential for serious adverse reactions, including opioid withdrawal, in breastfed infants, advise women that breastfeeding is not recommended during treatment with RELISTOR. In nursing mothers, a decision should be made to discontinue nursing or discontinue the drug, taking into account the importance of the drug to the mother.
  • A dosage reduction of RELISTOR tablets and RELISTOR injection is recommended in patients with moderate and severe renal impairment (creatinine clearance less than 60 mL/minute as estimated by Cockcroft-Gault). No dosage adjustment of RELISTOR tablets or RELISTOR injection is needed in patients with mild renal impairment.
  • A dosage reduction of RELISTOR tablets is recommended in patients with moderate (Child-Pugh Class B) or severe (Child-Pugh Class C) hepatic impairment. No dosage adjustment of RELISTOR tablets is needed in patients with mild hepatic impairment (Child-Pugh Class A). No dosage adjustment of RELISTOR injection is needed for patients with mild or moderate hepatic impairment. In patients with severe hepatic impairment, monitor for methylnaltrexone-related adverse reactions and dose adjust per Prescribing Information as may be indicated.
  • In the clinical studies, the most common adverse reactions were:

OIC in adult patients with chronic non-cancer pain

  • RELISTOR tablets (≥ 2% of RELISTOR patients and at a greater incidence than placebo): abdominal pain (14%), diarrhea (5%), headache (4%), abdominal distention (4%), vomiting (3%), hyperhidrosis (3%), anxiety (2%), muscle spasms (2%), rhinorrhea (2%), and chills (2%).
  • RELISTOR injection (≥ 1% of RELISTOR patients and at a greater incidence than placebo): abdominal pain (21%), nausea (9%), diarrhea (6%), hyperhidrosis (6%), hot flush (3%), tremor (1%), and chills (1%).

OIC in adult patients with advanced illness

  • RELISTOR injection (≥ 5% of RELISTOR patients and at a greater incidence than placebo): abdominal pain (29%), flatulence (13%), nausea (12%), dizziness (7%), and diarrhea (6%).

To report SUSPECTED ADVERSE REACTIONS, contact Salix Pharmaceuticals at 1-800-321-4576 or FDA at  1-800-FDA-1088 or www.fda.gov/medwatch.

Please click here for full Prescribing Information for RELISTOR tablets and RELISTOR injection.

References: 1. Data on File. PA Approval. Salix Pharmaceuticals, Bridgewater, NJ.  2. RELISTOR [prescribing information]. Bridgewater, NJ: Salix Pharmaceuticals. 3. ICD-10. Centers for Medicare & Medicaid Services: https://www.cms.gov/medicare/coding-billing/icd-10-codes. Updated April 1, 2026. Accessed April 9, 2026.