MedicaidCoverageMedium impact
October 2025 UPMC for You and UPMC Community HealthChoices formulary update
UPMC Health Plan·PA · Dermatology, Gastroenterology, Pharmacy·Pharmacy
Effective date
Oct 1, 2025
We identified it
Aug 7, 2026
Summary
Effective October 1, 2025, UPMC for You and UPMC Community HealthChoices will no longer cover Xifaxan (all strengths) and Retin-A (cream, gel) due to nonparticipation in the Medicaid Drug Rebate Program. Limited exception: Xifaxan 200 mg tablet is covered ONLY for hepatic encephalopathy diagnosis with prior authorization. Covered alternatives are available for both medications. Billing teams must update formulary references, implement prior authorization workflows for the narrow Xifaxan exception, and communicate alternative options to providers.
Action Required
By September 30, 2025: (1) Billing team must update pharmacy formulary system to reflect non-coverage of Xifaxan (all strengths) and Retin-A (cream, gel) under UPMC for You and UPMC Community HealthChoices plans. (2) Configure system to flag and require prior authorization when Xifaxan 200 mg tablet is billed with diagnosis code for hepatic encephalopathy only; route these for clinical review to ensure dose/duration aligns with national compendia or peer-reviewed literature. (3) Update prior authorization templates and denial templates in billing software. (4) Clinical staff and providers must be notified of covered alternatives: tretinoin cream (for Retin-A) and loperamide capsule, dicyclomine, lactulose solution, or azithromycin (for Xifaxan). (5) Create referral process for patients to manufacturer patient assistance program (1-833-862-8727 or bauschhealthpap.com) for Xifaxan coverage outside insurance. Claims submitted without prior authorization or for non-approved Xifaxan indications will be denied.