Prior authorization required

Does Bravo Health Pennsylvania, INC. require prior authorization for XIFAXAN?

Bravo Health Pennsylvania, INC. requires prior authorization for XIFAXAN on every Medicare Part D plan of theirs that covers it.

Every plan from this payer that covers the drug requires authorization before it is dispensed.

By product strength

RxNorm product	Plans covering	Require prior auth	Step therapy	Qty limit	Status
rifaximin 200 MG Oral Tablet [XIFAXAN]539789	35 / 35	35	0	35	Prior authorization required
rifaximin 550 MG Oral Tablet [XIFAXAN]856666	35 / 35	35	0	35	Prior authorization required

Product names come from RxNorm (U.S. National Library of Medicine).

Plan-by-plan detail — rifaximin 200 MG Oral Tablet [XIFAXAN]

XIFAXAN has 2 products in the corpus; this table is for rifaximin 200 MG Oral Tablet [XIFAXAN], the one carried on the most plans. The product table above covers every strength.

Plan	Contract	Tier	Prior auth	Step therapy	Qty limit
HealthSpring Achieve (HMO C-SNP)	H0354-027	4	Yes	No	Yes
HealthSpring Achieve (HMO C-SNP)	H3949-024	4	Yes	No	Yes
HealthSpring Alliance (HMO)	H0354-028	4	Yes	No	Yes
HealthSpring Preferred (HMO)	H0354-001	4	Yes	No	Yes
HealthSpring Preferred (HMO)	H3949-035	4	Yes	No	Yes
HealthSpring Preferred (HMO)	H3949-045	4	Yes	No	Yes
HealthSpring Preferred (HMO)	H3949-047	4	Yes	No	Yes
HealthSpring Preferred (HMO)	H3949-049	4	Yes	No	Yes
HealthSpring Preferred (HMO)	H3949-052	4	Yes	No	Yes
HealthSpring Preferred (HMO)	H3949-054	4	Yes	No	Yes
HealthSpring Preferred (HMO)	H9725-009	4	Yes	No	Yes
HealthSpring Preferred (HMO)	H9725-009	4	Yes	No	Yes
HealthSpring Preferred (HMO)	H9725-009	4	Yes	No	Yes
HealthSpring Preferred (HMO)	H9725-009	4	Yes	No	Yes
HealthSpring Preferred Full Savings (HMO)	H0354-030	4	Yes	No	Yes
HealthSpring Preferred PA (HMO)	H3949-031	4	Yes	No	Yes
HealthSpring Preferred Plus (HMO)	H3949-030	4	Yes	No	Yes
HealthSpring Preferred Plus (HMO)	H3949-048	4	Yes	No	Yes
HealthSpring Preferred Plus (HMO)	H9725-017	4	Yes	No	Yes
HealthSpring Preferred Plus (HMO)	H9725-017	4	Yes	No	Yes
HealthSpring Preferred Plus (HMO)	H9725-017	4	Yes	No	Yes
HealthSpring Preferred Plus (HMO)	H9725-017	4	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H0354-029	4	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H3949-053	4	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H9725-015	4	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H9725-015	4	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H9725-015	4	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H9725-015	4	Yes	No	Yes
HealthSpring Preferred Savings (HMO)	H9725-016	4	Yes	No	Yes
HealthSpring Preferred Select (HMO)	H9725-014	4	Yes	No	Yes
HealthSpring Premier (HMO-POS)	H9725-018	4	Yes	No	Yes
HealthSpring TotalCare (HMO D-SNP)	H9725-003	4	Yes	No	Yes
HealthSpring TotalCare Plus (HMO D-SNP)	H2752-003	4	Yes	No	Yes
HealthSpring TotalCare Plus (HMO D-SNP)	H3949-009	4	Yes	No	Yes
HealthSpring TotalCare Plus (HMO D-SNP)	H9725-013	4	Yes	No	Yes

Source

Monthly Prescription Drug Plan Formulary and Pharmacy Network Information — Basic Drugs Formulary File

Effective: 2026-06-30
Retrieved: 2026-07-19
SHA-256: e626e6bcda1aa6a0071e6f0df6bafe686ae41842cdf0a9feffdc649b6d3ff3ae

We publish the hash of the exact file we ingested so any answer can be audited against the bytes CMS served that day.

XIFAXAN at other payers

Or see XIFAXAN across every payer at once.

Administrative information only. Benefily reports what a payer has published in its own prior-authorization policy as of the effective date shown. It is not medical advice, not a coverage or payment guarantee, and not an authorization. Requirements vary by plan, place of service and member benefits — always verify with the payer before rendering service.