Does Upmc Health Network, INC. require prior authorization for XIFAXAN?
Prior authorization for XIFAXAN differs across Upmc Health Network, INC.'s Medicare Part D plans and product strengths — 2 of 2 XIFAXAN products in the corpus appear on their formularies, and the requirement is not uniform. Check the member's specific plan.
Some plans require authorization and others do not. The member's specific plan decides.
By product strength
| RxNorm product | Plans covering | Require prior auth | Step therapy | Qty limit | Status |
|---|---|---|---|---|---|
| rifaximin 200 MG Oral Tablet [XIFAXAN]539789 | 12 / 12 | 0 | 0 | 12 | No prior authorization |
| rifaximin 550 MG Oral Tablet [XIFAXAN]856666 | 12 / 12 | 12 | 0 | 12 | 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 |
|---|---|---|---|---|---|
| UPMC for Life PPO Essential Care Rx (PPO) | H5533-017 | 4 | No | No | Yes |
| UPMC for Life PPO Essential Care Rx (PPO) | H5533-017 | 4 | No | No | Yes |
| UPMC for Life PPO High Deductible Rx (PPO) | H5533-003 | 4 | No | No | Yes |
| UPMC for Life PPO Premier Rx (PPO) | H5533-011 | 4 | No | No | Yes |
| UPMC for Life PPO Premier Rx (PPO) | H5533-013 | 4 | No | No | Yes |
| UPMC for Life PPO Rx Choice (PPO) | H5533-015 | 4 | No | No | Yes |
| UPMC for Life PPO Rx Choice (PPO) | H5533-015 | 4 | No | No | Yes |
| UPMC for Life PPO Rx Choice (PPO) | H5533-015 | 4 | No | No | Yes |
| UPMC for Life PPO Rx Choice (PPO) | H5533-015 | 4 | No | No | Yes |
| UPMC for Life PPO Rx Choice (PPO) | H5533-015 | 4 | No | No | Yes |
| UPMC for Life PPO Rx Enhanced (PPO) | H5533-005 | 4 | No | No | Yes |
| UPMC for Life PPO Rx Enhanced (PPO) | H5533-008 | 4 | No | No | Yes |
- Effective
- 2026-06-30
- Retrieved
- 2026-07-19
- SHA-256
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XIFAXAN at other payers
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.