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Xifaxan — Blue Cross Blue Shield of New Mexico

irritable bowel syndrome with diarrhea (IBS-D)

Initial criteria

  • ONE of the following:
  • A. The patient has a diagnosis of irritable bowel syndrome with diarrhea (IBS-D) AND BOTH of the following:
  • 1. The patient has NOT received 3 or more 14-day treatment courses in the previous 12 months AND
  • 2. ONE of the following: the patient is currently being treated and stable on the requested agent OR has tried and had an inadequate response to ONE tricyclic antidepressant agent OR ONE tricyclic antidepressant agent was discontinued due to lack of efficacy, diminished effect, or adverse event OR has intolerance or hypersensitivity to ONE tricyclic antidepressant agent OR has an FDA labeled contraindication to ONE tricyclic antidepressant agent OR ONE tricyclic antidepressant is expected to be ineffective or not in best interest based on medical necessity OR has tried another prescription drug in same class as one tricyclic antidepressant and discontinued due to lack of efficacy or adverse event
  • B. The patient is at risk of recurrent overt hepatic encephalopathy OR
  • C. The patient has another FDA labeled indication for Rifaximin OR
  • D. The patient has another indication supported in compendia for the requested agent and route of administration AND
  • If the patient has an FDA labeled indication, then ONE of the following: (A) The patient’s age is within FDA labeling for the indication OR (B) There is support for use at the patient’s age
  • The patient does NOT have any FDA labeled contraindications to the requested agent

Reauthorization criteria

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

Approval duration

3 months (BCBSNM IBS-D); 12 months (hepatic encephalopathy or other indications)