Xifaxan (rifaximin) — Point32Health

Initial criteria

• The patient has a documented diagnosis of small intestine bacterial overgrowth
• The prescribing physician is a gastroenterologist
• The patient has failed to respond to at least two different classes of antibiotic treatment (e.g., ciprofloxacin, metronidazole, amoxicillin-clavulanate, trimethoprim-sulfamethoxazole) OR the patient has contraindication to all these antibiotic treatments: ciprofloxacin, metronidazole, amoxicillin-clavulanate

Reauthorization criteria

• Subsequent treatment cycle requires reauthorization

Approval duration

14 days per treatment cycle, up to 2 cycles per 365 days