Xifaxan (Rifaximin) Prior Authorization Of Benefits (Pab) Form
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1
2CONTAINS CONFIDENTIAL PATIENT INFORMATION
Xifaxan (rifaximin)
Prior Authorization of Benefits (PAB) Form
Complete form in its entirety and fax to:
Prior Authorization of Benefits Center at (800) 601- 4829
1. PATIENT INFORMATION
2. PHYSICIAN INFORMATION
Patient Name: _______________________________
Prescribing Physician: ____________________________
Patient ID #:
_______________________________
Physician Specialty:
____________________________
Patient DOB: _______________________________
Physician Phone #:
_____________________________
Date of Rx:
_______________________________
Physician Fax #:
_____________________________
Patient Phone #: ____________________________
Physician Address:
_____________________________
Patient Email Address: ________________________
Physician DEA:
____________________________
Physician NPI #:
_____________________________
Physician Email Address: ___________________________
3. MEDICATION
4. STRENGTH
5. DIRECTIONS
6. QUANTITY PER 30 DAYS
□
□
Xifaxan (rifaximin)
______________________
Specify: _________________
200mg
550mg
7. DIAGNOSIS: ___________________________________________________________________________________
CHECK ALL BOXES THAT APPLY
8. APPROVAL CRITERIA:
NOTE: Any areas not filled out are considered not applicable to your patient & MAY AFFECT THE OUTCOME of this request.
200mg tablets
□
□
No
Patient has a documented diagnosis of travelers’ diarrhea caused by non-invasive strains of
Yes
Eschenrichi coli
□
□
Yes
No
Patient has already started Xifaxan and needs to complete treatment
□
□
Yes
No
Patient has had a trial and inadequate response or intolerance to one of the following medications:
generic fluoroquinolone OR azithromycin
□
□
Yes
No
Patient has a contraindication to generic fluoroquinolone AND azithromycin
□
□
Yes
No
Patient is 12 years of age or older
550mg tablets
□
□
Yes
No
Xifaxan (rifaximin) is being used to reduce the risk of overt hepatic encephalopathy (HE) recurrence
□
□
Yes
No
Patient has had a trial and inadequate response to lactulose
□
□
Yes
No
Patient has an intolerance or contraindication to lactulose
□
□
Yes
No
Xifaxan (rifaximin) is being used for the treatment of irritable bowel syndrome with diarrhea (IBS-D)
□
□
Yes
No
Patient has had a trial and inadequate response or intolerance to ONE of the
following medications: loperamide, antispasmodics (hyoscyamine, dicyclomine),
or tricyclic antidepressants
□
□
Yes
No
Patient has a contraindication to ALL of the following medications: loperamide,
antispasmodics (hyoscyamine, dicyclomine), or tricyclic antidepressants
□
□
Yes
No
Patient is 18 years of age or older
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Xifaxan NTL PAB Fax Form 12.12.15.doc
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