Xifaxan — United Healthcare

Preferred products

• tricyclic antidepressant (e.g., amitriptyline)
• Viberzi

Initial criteria

• Diagnosis of IBS-D
• History of failure, contraindication or intolerance to a tricyclic antidepressant (e.g., amitriptyline)
• History of failure, contraindication or intolerance to Viberzi OR history of or potential for a substance abuse disorder

Reauthorization criteria

• Patient has experienced a recurrence of IBS-D after a prior 14 day course of therapy with Xifaxan
• Patient has had a treatment-free period between courses of therapy
• Patient has not already received 3 treatment courses of Xifaxan for IBS-D in the previous 6 months

Approval duration

14 days