Medicare AdvantagePrior AuthMedium impact
Xifaxan® (rifaximin) (Revised)
Humana·Gastroenterology, Internal Medicine, Infectious Disease·Medicare Advantage
Effective date
Jan 1, 2024
We identified it
Jun 25, 2026
Summary
This is a revised Humana Medicare Advantage prior authorization policy for Xifaxan® (rifaximin) effective January 1, 2024, with the most recent revision dated June 24, 2026. The policy establishes prior authorization requirements for three indications: IBS-D (requires diagnosis confirmation and age ≥18), travelers' diarrhea (requires non-invasive E. coli confirmation, no fever/blood in stool, age ≥12, and failure of fluoroquinolones/azithromycin), and hepatic encephalopathy recurrence prevention (requires prior HE episode, age ≥18). All approvals are limited to plan year duration with renewal requirements.
Action Required
By January 1, 2024 (retroactive implementation advised): Billing team must establish prior authorization workflow for all Xifaxan® (rifaximin) prescriptions in the billing system. For each claim, verify prior authorization approval based on the three indication pathways: (1) IBS-D claims require member age ≥18 and IBS-D diagnosis documentation; (2) travelers' diarrhea claims require member age ≥12, documented non-invasive E. coli infection without fever or bloody stool, and evidence of failed trial or contraindication to ciprofloxacin, levofloxacin, or azithromycin; (3) hepatic encephalopathy claims require member age ≥18, documented prior overt HE episode, and confirmation that Xifaxan is for recurrence prevention. Coordinate with clinical review staff and prescribers to ensure adequate documentation prior to claim submission. Set renewal reminders for plan year duration. Claims submitted without corresponding prior authorization or missing required documentation will be denied. Update EMR/EHR templates and encounter forms to prompt providers for complete clinical information required for authorization.