Rifaximin 550mg — Blue Cross Blue Shield of Illinois

Initial criteria

• ONE of the following:
• A. Diagnosis of IBS-D AND BOTH of the following:
• 1. Patient has NOT received 3 or more 14-day treatment courses in previous 12 months AND
• 2. ONE of the following:
• a. Patient currently treated and stable on requested agent (chart notes required) OR
• b. Tried and had inadequate response to ONE tricyclic antidepressant (chart notes required) OR
• c. Discontinued ONE tricyclic antidepressant due to lack of efficacy, diminished effect, or adverse event (chart notes required) OR
• d. Intolerance or hypersensitivity to ONE tricyclic antidepressant not expected with requested agent (chart notes required) OR
• e. FDA labeled contraindication to ONE tricyclic antidepressant not expected with requested agent (chart notes required) OR
• f. ONE tricyclic antidepressant expected to be ineffective based on clinical characteristics (chart notes required) OR
• g. ONE tricyclic antidepressant not in best interest based on medical necessity (chart notes required) OR
• h. Tried another prescription drug in same pharmacologic class or same mechanism as ONE tricyclic antidepressant and discontinued due to lack of efficacy or adverse event (chart notes required)
• B. Patient is at risk of recurrent overt hepatic encephalopathy OR
• C. Patient has another FDA labeled indication for requested agent OR
• D. Patient has another indication supported in compendia for requested agent and route of administration
• AND if patient has an FDA labeled indication, ONE of the following:
• A. Patient’s age is within FDA labeling for indication OR
• B. There is support for using requested agent for patient’s age for requested indication
• AND Patient does NOT have any FDA labeled contraindications to requested agent

Reauthorization criteria

• 1. Patient previously approved for requested agent through plan’s Prior Authorization process AND
• 2. ONE of the following:
• A. Patient has diagnosis of IBS-D AND ALL of the following:
• 1. Had clinical benefit with requested agent AND
• 2. Had treatment-free period AND
• 3. Has NOT received 3 or more 14-day treatment courses in previous 12 months OR
• B. Patient is at risk of recurrent overt hepatic encephalopathy AND has had clinical benefit with requested agent OR
• C. Patient has another FDA labeled indication AND has had clinical benefit OR
• D. Patient has another indication supported in compendia and route of administration AND has had clinical benefit
• AND Patient does NOT have any FDA labeled contraindications to requested agent

Approval duration

12 months (IBS-D: BCBSIL 12 months; BCBSMT & BCBSNM 3 months; others 1 month; hepatic encephalopathy 12 months; other indications 12 months)