CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Rifaximin (Xifaxan) coverage

Criteria and authorization limits for coverage of rifaximin (Xifaxan) for travelers' diarrhea, irritable bowel syndrome with diarrhea (IBS-D), and hepatic encephalopathy for Medicaid members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRifaximin (Xifaxan) coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDec 1, 2017

Next Review DateN/A

Key ActionObtain prior authorization and document prior treatment failures or contraindications as specified for the requested indication.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3indications covered

1,1,12 moapproval durations

tablet limitsapproval limits

07/2025last review

Coverage Criteria for Rifaximin (Xifaxan)

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Traveler's Diarrhea: 1) Traveler's diarrhea caused by noninvasive strains of Escherichia coli; 2) Member is 12 years of age or older; 3) Member has experienced an inadequate treatment response, intolerance, or contraindication to both a fluoroquinolone (e.g., ciprofloxacin, levofloxacin) and azithromycin.authorization: 1 month; approval limit: 200 mg tablet, 9 tablets

Irritable Bowel Syndrome with Diarrhea

Authorization of 1 month may be granted for treatment of IBS-D in members 18 years and older when ALL of the following are met:

IBS-D: 1) Member has experienced an inadequate treatment response, intolerance, or contraindication to two generic medications for diarrhea symptoms (e.g., loperamide and a bile acid sequestrant); 2) Member has abdominal pain/bloating and has experienced an inadequate treatment response, intolerance, or contraindication to short-term trials with two generic antispasmodic medications for abdominal pain such as dicyclomine, hyoscyamine IR or hyoscyamine ER; 3) Member has received less than a total of three 14-day course treatments.authorization: 1 month; approval limit: 550 mg tablet, 42 tablets

Hepatic Encephalopathy

Authorization of 12 months may be granted for hepatic encephalopathy in members 18 years and older when the following is met:

Hepatic Encephalopathy (initial): Member has experienced an inadequate treatment response, intolerance, or contraindication to lactulose for control of ammonia levels.authorization: 12 months; approval limit: 550 mg tablet, 60 tablets

Hepatic Encephalopathy (maintenance): Member achieves or maintains positive clinical response with Xifaxan as evidenced by a decrease in serum ammonia levels and/or improvement in member's mental status.authorization: 12 months

Use of rifaximin for indications other than the three specifically covered conditions — traveler’s diarrhea, irritable bowel syndrome with diarrhea (IBS‑D), and hepatic encephalopathy — is not specified in this policy and therefore would not meet the indication‑specific criteria required for authorization.

Provider Actions, Requirements, and Denial Triggers

Prior Authorization

Prior Authorization Required

Prior authorization is required and will be granted only when the indication-specific criteria are met, including required prior treatment failure, intolerance, or contraindication to specified alternatives and any age limits.

Authorization durations: Traveler's diarrhea — up to 1 month; IBS-D — up to 1 month; Hepatic encephalopathy — up to 12 months.

Step Therapy

Step Therapy Requirements

Step therapy is required for specific indications. For traveler's diarrhea and IBS-D, the member must have tried and had inadequate response, intolerance, or contraindication to the specified alternative therapies before authorization will be considered.

Traveler's diarrhea: inadequate response/intolerance/contraindication to both a fluoroquinolone (e.g., ciprofloxacin, levofloxacin) and azithromycin.
Irritable bowel syndrome with diarrhea (IBS‑D): inadequate response/intolerance/contraindication to two generic antidiarrheal medications (e.g., loperamide and a bile acid sequestrant) and to short-term trials of two generic antispasmodics (e.g., dicyclomine, hyoscyamine IR or ER).

Documentation Required

Required Documentation

Documentation must support the specific indication, member age, prior inadequate response/intolerance/contraindication to the specified alternatives, and prior exposure limits where applicable.

For Traveler's Diarrhea: documentation that TD is caused by noninvasive strains of Escherichia coli; member age ≥ 12; records showing prior inadequate response/intolerance/contraindication to both a fluoroquinolone and azithromycin.
For IBS‑D: documentation of member age ≥ 18; records showing prior inadequate response/intolerance/contraindication to two generic antidiarrheal agents and to two short-term trials of generic antispasmodics; documentation that the member has received fewer than three total 14‑day course treatments.
For Hepatic Encephalopathy: documentation of member age ≥ 18 and prior inadequate response/intolerance/contraindication to lactulose; for continuation, documentation of clinical benefit (decrease in serum ammonia and/or improvement in mental status).

Denial Risk

Denial Triggers

Requests that do not meet the listed indication‑specific criteria will be denied.

Denial triggers include: • Missing documentation of prior trials or intolerance/contraindication to required alternatives. • Age below indication-specific minimums (TD < 12 years; IBS‑D or hepatic encephalopathy < 18 years). • For TD: absence of documentation that infection is due to noninvasive E. coli when applicable. • For IBS‑D: failure to document required prior trials of two antidiarrheals and two antispasmodics, or having already received three or more 14‑day courses. • For hepatic encephalopathy: lack of prior lactulose trial or lack of documented clinical response for continuation requests.

Definitions

Traveler's diarrhea (TD) — definition and requirements

DefinitionDiarrhea caused by noninvasive strains of Escherichia coli.

Age requirementMember is 12 years of age or older.

Step/ prior therapy requirementMember has experienced inadequate response, intolerance, or contraindication to both a fluoroquinolone (e.g., ciprofloxacin, levofloxacin) and azithromycin.

Irritable Bowel Syndrome with Diarrhea (IBS-D) — definition and requirement

DefinitionIrritable bowel syndrome with predominant diarrhea (IBS‑D).

Age requirementMember is 18 years of age or older.

Step/ prior therapy requirementsMember has had inadequate response, intolerance, or contraindication to two generic antidiarrheal medications (e.g., loperamide and a bile acid sequestrant) and to short-term trials of two generic antispasmodics (e.g., dicyclomine, hyoscyamine IR or ER).

Hepatic encephalopathy — definition and requirements

DefinitionEncephalopathy related to chronic liver disease for which rifaximin is used to reduce recurrence/manage symptoms.

Age requirementMember is 18 years of age or older.

Step/ prior therapy and continued authorizationInitial authorization requires inadequate response, intolerance, or contraindication to lactulose for control of ammonia levels; continued authorization requires achievement or maintenance of clinical improvement (decreased serum ammonia and/or improved mental status).

Background

Rifaximin is a minimally absorbed, gut‑targeted antibiotic used in select gastrointestinal conditions. In this policy it is covered with criteria for three indications: traveler’s diarrhea caused by noninvasive Escherichia coli (authorization up to 1 month for patients ≥12 years after failed or intolerant trials of both a fluoroquinolone and azithromycin), IBS‑D in adults ≥18 years (authorization up to 1 month when prior trials of two generic antidiarrheals and two antispasmodics have failed or are not tolerated, and with limits on the total number of 14‑day courses), and hepatic encephalopathy in adults ≥18 years (authorization up to 12 months when lactulose has been ineffective or not tolerated; continued use requires demonstration of clinical benefit).

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyRifaximin (Xifaxan) coverage

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateDec 1, 2017

Next Review DateN/A

Key ActionObtain prior authorization and document prior treatment failures or contraindications as specified for the requested indication.

SourceLink

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