CurrentAnthemPolicy N/A

Prior authorization request form — Dificid (fidaxomicin)

This document governs the prior authorization (PA) request process for Dificid (fidaxomicin) for members served by Anthem Blue Cross and Blue Shield in Indiana programs (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, Indiana PathWays for Aging). It specifies required form completion, submission instructions, and PA clinical requirements.

Policy Summary

PayerAnthem

PolicyPrior authorization request form — Dificid (fidaxomicin)

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateN/A

Next Review DateN/A

Key ActionComplete the PA form in its entirety and fax to the Prior Authorization or Benefits Center at 844-864-7860 (retail) or 888-209-7838 (medical injectable).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2dosage forms listed

6+programs covered

2 numsPA submission faxes

>=6 mominimum age

preferred brandformulary preference

Prior Authorization Approval Criteria

PA approval criteria

Criteria that must be met and documented on the PA form for approval:

ALL of the following

ALL of the following
- Member is six months of age or older>= 6 months
  Document response on form
ALL of the following
- Member has a diagnosis of Clostridium difficile infection (CDI)
  Document diagnosis on form
ALL of the following

Policy Summary

PayerAnthem

PolicyPrior authorization request form — Dificid (fidaxomicin)

Policy CodePolicy N/A

Change TypeMinor / informational

Effective DateN/A

Next Review DateN/A

Key ActionComplete the PA form in its entirety and fax to the Prior Authorization or Benefits Center at 844-864-7860 (retail) or 888-209-7838 (medical injectable).

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Medication Formulation and Dosing

Medication formulationsNDC

Dificid 200mg tablet	Dificid 200mg tablet
Dificid 200mg/5mL suspension	Dificid 200mg/5mL suspension

Quantity and dosing (request form fields)

Form fields presentPA form includes explicit fields to specify requested formulation (Dificid 200 mg tablet or 200 mg/5 mL suspension), a Quantity field, and a Dosing field (provider must enter numeric values)

No numeric thresholds providedThe form requires the prescriber to enter quantity and dosing but does not specify maximum or standard numeric thresholds on the form

Formulation choice impacts documentationForm asks whether member can swallow tablets to guide choice between tablet and suspension formulations

Submission, Retroactive Requests, and Clinical Requirements

Prior Authorization

Submission and completion instructions

Complete the prior authorization (PA) form in its entirety and fax to the Prior Authorization or Benefits Center. Use 844-864-7860 for retail PA requests and 888-209-7838 for medical injectable PA requests. The form must be completed by the prescribing provider; all sections must be filled or the request will be returned. Providers contracted with Anthem programs (Hoosier Healthwise, Healthy Indiana Plan, Hoosier Care Connect, Indiana PathWays for Aging via ACO/PMG/IPA) must follow their group guidelines for authorization, covered benefits, and claims submission.

Fax Prior Authorization/Benefits Center: 844-864-7860 (retail)
Fax Prior Authorization/Benefits Center: 888-209-7838 (medical injectable)

Prior Authorization

Retroactive prior authorization instructions

If requesting a retroactive prior authorization, indicate this on the form by selecting the Retroactive PA option and provide the date(s) of service requested for retroactive eligibility. Submit PA requests for retroactive claims (dates of service prior to eligibility determination but within established eligibility timelines) with dates of service prior to 30 calendar days of submission separately from current PA requests (which are dates of service 30 calendar days or less and going forward).

Select the Retroactive PA checkbox on the form when applicable
Enter the date(s) of service requested for retroactive eligibility
Submit retroactive PA requests with dates of service >30 days prior to submission separately from current PA requests

Documentation Required

Clinical prior authorization requirements and formulary preference

Clinical documentation must demonstrate a diagnosis of Clostridium difficile infection (CDI) and that the member is six months of age or older. Indicate whether the member can swallow the tablet formulation and select the applicable clinical scenario: initial episode with increased risk of recurrence (provide risk factors), initial episode with vancomycin‑resistant pseudomembranous colitis (documentation required), or recurrent episode of CDI. Note: the plan prefers the brand-name product Dificid (fidaxomicin); requests for generic fidaxomicin will require a generic medically necessary PA review.

Documentation of CDI diagnosis required
Member age ≥ 6 months
Document whether member can swallow tablet formulation
Select one clinical scenario: initial episode with increased risk for recurrence (provide risk factors), initial episode with vancomycin‑resistant pseudomembranous colitis (provide documentation), or recurrent CDI episode
Brand preference: Dificid preferred; generic fidaxomicin requires generic medically necessary PA review

Term Definitions and Confidentiality

Clostridium difficile infection (CDI) — PA diagnosis requirement

Required diagnosisPA requires documentation that the member has a diagnosis of Clostridium difficile infection (CDI)

Minimum ageMember must be six months of age or older

Clinical justification optionsForm requires selection of one clinical scenario: initial episode with increased recurrence risk (risk factors must be provided), initial episode with vancomycin-resistant pseudomembranous colitis (documentation required), or recurrent CDI

Swallowing abilityForm asks whether the member is able to swallow tablet formulation to determine appropriate formulation

Protected Health Information (PHI) / Confidential information notice

Confidentiality noticeDocuments transmitted with the PA form may contain confidential health information intended only for the named recipient; unauthorized disclosure is prohibited and must be reported if received in error

Restriction on PHI useRecipients are not permitted to use or disclose Protected Health Information about individuals they are not treating or not enrolled to their practice; applies to all mediums including mail, email, fax, or other electronic transmission

Action if received in errorIf you are not the intended recipient, notify the sender immediately and arrange for return or destruction of the documents