CurrentCignaPolicy N/A

Xifaxan (rifaximin) drug quantity management

Defines quantity limits and medical-necessity overrides for Xifaxan (rifaximin) tablets for Cigna-administered health benefit plans and describes approval duration and applicable indications.

Policy Summary

PayerCigna

PolicyXifaxan (rifaximin) drug quantity management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateSep 18, 2024

Key ActionIf the drug quantity management rule is not met at point of service, coverage will be determined by the stated criteria and approvals are provided for 1 year.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

9Retail max per Rx (200 mg)

27Home delivery max per Rx (200 mg)

60Retail max per Rx (550 mg)

180Home delivery max per Rx (550 mg)

300Retail override (200 mg)

900Home delivery override (200 mg)

Policy Summary

PayerCigna

PolicyXifaxan (rifaximin) drug quantity management

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateSep 18, 2024

Key ActionIf the drug quantity management rule is not met at point of service, coverage will be determined by the stated criteria and approvals are provided for 1 year.

SourceLink

On This Page

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Quantity Limits and Medical Necessity Exceptions

Quantity limits and exceptions

Standard quantity limits and medical-necessity exceptions for Xifaxan (rifaximin) tablets.

Drug Quantity Management program: approvals are provided for 1 year when criteria are met (see policy statement).

ALL of the following

Xifaxan 200 mg tablets — Retail maximum quantity per prescription: 9 tablets.
Xifaxan 200 mg tablets — Home delivery maximum quantity per prescription: 27 tablets.
Exceptions to the quantity limits above are covered as medically necessary only when the specific criteria below are met; any other exception is not medically necessary.

ALL of the following

Xifaxan 550 mg tablets — Retail maximum quantity per prescription: 60 tablets.
Xifaxan 550 mg tablets — Home delivery maximum quantity per prescription: 180 tablets.
No overrides recommended for Xifaxan 550 mg tablets.

Exception for Xifaxan 200 mg tablets

If the patient has chronic antibiotic-dependent pouchitis, approve up to 300 tablets per dispensing at retail.
If the patient has chronic antibiotic-dependent pouchitis, approve up to 900 tablets per dispensing for home delivery.
Approvals granted under this exception are provided for 1 year in duration.

Billing Guidance and Quantity Limits

Billing guidancemixed

No codes listed

Quantity limits and overrides

Retail maximum per prescription (200 mg)9 tablets

Home delivery maximum per prescription (200 mg)27 tablets

Retail maximum per prescription (550 mg)60 tablets

Home delivery maximum per prescription (550 mg)180 tablets

Override allowance (200 mg) — chronic antibiotic-dependent pouchitisApprove 300 tablets per dispensing at retail and 900 tablets per dispensing at home delivery

Prior Authorization and Override Process

Prior Authorization

Request prior authorization when quantity limits are exceeded

If the quantity limit is exceeded at the point of sale, submit a prior authorization request for a medical‑necessity review; coverage will be determined by the policy criteria and, if approved, all approvals are provided for 1 year.

If Drug Quantity Management rule is not met at point of service, coverage is determined by the Criteria.
All approvals are provided for 1 year in duration.

Key Terms

Xifaxan (rifaximin) — drug description, strengths, and indications

Generic nameRifaximin (Xifaxan)

Available strengths and formulations200 mg tablets (supplied in 30-tablet bottles); 550 mg tablets (supplied in 60-tablet bottles and blister packs)

IndicationsHepatic encephalopathy (reduce risk of overt disease in adults); Irritable bowel syndrome with diarrhea in adults; Travelers' diarrhea caused by noninvasive E. coli in patients ≥ 12 years

Typical dosing examplesHepatic encephalopathy: 550 mg twice daily; IBS-D: 550 mg three times daily for 14 days (may retreat up to 2 times if recurrence); Travelers' diarrhea: 200 mg three times daily for 3 days

Drug Quantity Management — program definition and override rationale

Program definition