Relistor

Indicated For

opioid-induced constipation

About This Medication

# Bausch Health Patient Assistance Program Patient Guide: How to Get Relistor at Low or No Cost ## About This Program The Bausch Health Patient Assistance Program (BHC PAP) is designed to help uninsured and underinsured patients access prescription medications manufactured by Bausch Health at no cost. If you have been prescribed Relistor (methylnaltrexone bromide) and are struggling with medication costs, this program may be able to provide your medication for free for up to 12 months. ## About Relistor Relistor is a prescription medication used to treat opioid-induced constipation in patients taking opioid pain medications. It works by blocking opioid receptors in the gut, allowing normal bowel function to resume without reducing pain relief. This medication is typically prescribed for patients on long-term opioid therapy who have not responded to other constipation treatments. ## Who Qualifies for This Program? You may be eligible for the Bausch Health Patient Assistance Program if you meet ALL of the following requirements: - You are a legal United States resident - You have a valid prescription from a licensed U.S. healthcare professional for Relistor - You are being treated as an outpatient (not hospitalized) - You do not reside in a nursing home, correctional facility, or court-appointed program - You meet the income eligibility requirements - You meet the insurance eligibility requirements ## Income Eligibility Your annual household income must not exceed **300% of the Federal Poverty Level (FPL)** based on your household size. The Federal Poverty Level guidelines are updated annually by the U.S. Department of Health and Human Services. As a reference, here are approximate 2026 income limits at 300% of FPL: | Household Size | Approximate Annual Income Limit | |---|---| | 1 person | $40,000 | | 2 people | $54,000 | | 3 people | $68,000 | | 4 people | $82,000 | | 5 people | $96,000 | | 6 people | $110,000 | These figures are estimates based on 2026 Federal Poverty Level guidelines. For exact current limits, visit https://aspe.hhs.gov/poverty-guidelines. ## Insurance Requirements You must fall into one of these categories: - **Uninsured**: You have no health insurance coverage - **Denied coverage**: Your commercial insurance denied coverage for Relistor and you have exhausted all appeal options - **No coverage through government programs**: You have Medicare Part D, Medicaid, VA, DoD, TRICARE, or other federal/state pharmacy assistance, but they do not cover Relistor - **Medicare Part D appeal**: If you have Medicare Part D coverage, you may appeal for eligibility evaluation on a case-by-case basis **Important note**: Discount cards are not considered prescription drug coverage for program eligibility purposes. ## Step-by-Step Application Process ### Step 1: Gather Required Documents Before starting your application, collect the following: - Your valid prescription for Relistor from your healthcare provider - Front and back copies of your medical insurance card (if you have one) - Front and back copies of your prescription drug insurance card (if you have one) - Proof of income (recent pay stubs, tax returns, or benefit statements) - Proof of residency (utility bill, lease agreement, or government-issued ID) ### Step 2: Complete the Patient Application 1. Download the application form from https://www.bauschhealthpap.com/siteassets/pdf/docs/bhc-bhpap-application-all-other-patients.pdf 2. Complete the Patient Information section with your name, address, phone number, and date of birth 3. Complete the Insurance Information section, listing all current health insurance and prescription drug coverage 4. Read and sign the Patient Authorization and Certification section 5. Attach copies of your insurance cards (front and back) **Special note for Medicaid patients**: If you are a Medicaid recipient, download and use the "Application for Medicaid-Only Patients" form instead. ### Step 3: Have Your Healthcare Provider Complete the Application Give your healthcare provider pages 4, 5, and 6 of the application form. Your provider must: - Verify your diagnosis and that Relistor is medically necessary - Confirm your prescription details - Sign the Prescriber Certification section - Use original signatures only (stamped signatures are not accepted for controlled substances) ### Step 4: Submit Your Application Once all sections are complete and signed, submit your application by: **Fax**: 844-705-0160 **Mail**: BAUSCH HEALTH PATIENT ASSISTANCE PROGRAM P.O. Box 991624 Louisville, KY 40269 **Important**: All required information marked with an asterisk (*) must be provided, or your application will be placed on hold until received. ## Timeline and Delivery After you submit your application: - **Processing time**: Typically 2-4 weeks - **Notification**: You will be notified of approval or denial status - **Delivery**: If approved, your medication will be shipped directly to you - **Coverage period**: You will receive assistance for up to 12 months from your approval date ## Reauthorization and Renewal If you are approved for the program: - **Annual reconfirmation**: The program will verify your income and insurance eligibility annually - **Medicare Part D patients**: You must reapply by December 31 each year to continue in the program for the following year - **Changes in circumstances**: If your income or insurance status changes, you may become ineligible and should notify the program immediately - **Reapplication**: If you continue to meet eligibility requirements, you may reapply annually for continued assistance ## What If Your Application Is Denied? If your application is denied, you have several options: - **Request clarification**: Contact the program to understand why you were denied - **Appeal**: If circumstances have changed or you believe an error was made, you may submit additional documentation for reconsideration - **Explore alternatives**: Ask your healthcare provider about generic alternatives, other patient assistance programs, or pharmaceutical company discount programs - **Contact patient advocacy**: Organizations like the Patient Advocate Foundation may be able to provide additional resources ## Important Disclaimers - All applications are reviewed on a case-by-case basis - There is no cost to apply - Bausch Health Companies Inc. reserves the right to determine your participation in the program - This program is subject to change at any time - Your prescriber must not be on the List of Excluded Individuals and Entities maintained by the Office of Inspector General - This guide provides general information and should not be considered medical or legal advice ## Questions? For more information about the Bausch Health Patient Assistance Program, visit BauschHealthPAP.com or contact the program at the fax or mailing address listed above.

Program information last verified: March 30, 2026