Limited Coverage Drugs – Rifaximin

Generic Name:

rifaximin

Strength:

550 mg

Form:

Oral tablet

Special Authority Criteria

Approval Period

For reducing the risk of overt hepatic encephalopathy (HE) recurrence in patients who meet the following criteria:

  • have been hospitalized with HE associated with cirrhosis of the liver; 

AND

  • are unable to achieve adequate control despite taking the maximum tolerated dose of lactulose;

AND

  • rifaximin must be prescribed by an internal medicine specialist or a gastroenterologist.

Rifaximin should be used in combination with a maximal tolerated dose of lactulose.

Six months

Practitioner Exemptions

  • No practitioner exemptions.

Special Notes

  • None

Special Authority Request Form(s)