Relistor® (methylnaltrexone)

Medical benefit authorization forms

Traditional & Optimized 

Medicare Part B

Priority Health Medicaid no longer utilizes drug-specific prior authorization forms. Visit the Medicaid Approved Drug List (ADL) to find the new PA form and drug criteria document.

Go to Medicaid ADL

For further information on medical drugs, please see the Injectable drugs page.

Code(s): J2212

Benefit: Medical

Notes: Treatment of opioid-induced constipation