Xifaxan — United Healthcare
Hepatic Encephalopathy
Preferred products
- lactulose
Initial criteria
- Diagnosis of hepatic encephalopathy
- Used as add-on therapy to lactulose AND patient is unable to achieve an optimal clinical response with lactulose monotherapy OR history of contraindication or intolerance to lactulose
Reauthorization criteria
- Documentation of positive clinical response to Xifaxan therapy
Approval duration
12 months