Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 09/01/2016 Title: Xifaxin (Rifaximin) 550mg Tabs
Revision Date: Document: BI515:00
CPT Code(s): None
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Xifaxin (Rifaximin) 550mg tablets require prior authorization. Criteria include use of first-line agents before approval of Xifaxan 550mg.

2)    Xifaxin 550mg is used to treat hepatic encephalopathy and irritable bowel syndrome with diarrhea (IBS-D).

3)    Xifaxan 550mg tablets are not approved for use to treat Traveler’s Diarrhea.


Medical Statement

Xifaxin (Rifaximin) 550mg tablets are considered medically necessary for members 18 years of age and older who meet the following criteria:

 

§  Diagnosis of hepatic encephalopathy AND

§  Have experienced a therapeutic failure or contraindication to Lactulose

 

OR

 

·       Diagnosis of irritable bowel syndrome with diarrhea (IBS-D) AND

·       Is prescribed to be dosed 3 times per day x 14 days AND

·       Has had a trial and inadequate response or intolerance to one of the following medications or has a contraindication to all of the following medications:

o   Loperamide OR

o   Antispasmodics (i.e. Hyoscyamine, Dicyclomine) OR

o   Tricyclic Antidepressants


Limits

For IBS-D, only allowed 42 x 550mg tablets for 14 day supply; must be at least a 10 week break before retreatment will be approved; only allowed 3 treatments per year.


Reference

1)    Xifaxan Package Insert.  Salix Pharmaceuticals. Bridgewater, NJ. November 2015.

2)    Clinical Pharmacology.  Accessed online 06-08-2016

3)    Vilstrup H, modio P, Bajaj J, et al. Hepatic Encephalopathy in Chronic Liver Disease: 2014 Practice Guideline by American Association for the Study of Liver Diseases, and the European Association for the Study of the Liver. Hepatology. 2014; 60(2):715-35.

4)    Weinberg DS, Smalley W, Heidelbaugh JJ, et. al. American Gastroenterological Association Institute Guideline on the Pharmacological Management of Irritable Bowel Syndrome. Gastroenterology. 2014; 147(5):1146-48.


Application to Products

This policy applies to all health plans and products administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet.  Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) or Certificate of Coverage (COC) for those plans or products insured by QualChoice.  In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC or COC, the SPD, EOC, or COC, as applicable, will prevail.  State and federal mandates will be followed as they apply.


Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
This policy has recently been updated. Please use the index above or enter policy title in search bar for the latest version.