Limited coverage criteria – rifaximin

Last updated on April 3, 2025

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Generic name		rifaximin
Strength & form		550 mg 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 A Special Authority request is submitted by an internal medicine specialist or a gastroenterologist	6 months

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

A Special Authority request is submitted by an internal medicine specialist or a gastroenterologist

6 months

Practitioner exemptions

None

Special notes

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

Special Authority request form(s)

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HLTH 5483 – Rifaximin (PDF, 463KB)

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