02/26/2015 Service Authorization CHRISTUS Health Plan (Medicaid) Xifaxan 550mg (Medicaid) This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information, sign and date. Fax signed forms to CHRISTUS Health Plan (Medicaid) at 1-866-255-7569. Please contact CHRISTUS Health Plan (Medicaid) at 1-855-656-0363 with questions regarding the prior authorization process. When conditions are met, we will authorize the coverage of Xifaxan 550mg (Medicaid). Drug Name (select from list of drugs shown) Xifaxan 550mg (rifaximin) Quantity Route of Administration Frequency Expected Length of therapy Strength Patient Information Patient Name: Patient ID: Patient Group No.: Patient DOB: Patient Phone: Prescribing Physician Physician Name: Physician Phone: Physician Fax: Physician Address: City, State, Zip: Diagnosis: ICD Code: Please circle the appropriate answer for each question. Question 1. Is the patient greater than or equal to 18 years of age? Circle Yes or No Y N [If the answer to this question is no, then no further questions required.] 2. Does the patient have a diagnosis of hepatic encephalopathy in the last 730 days? Y N Y N [If the answer to this question is no, then no further questions required.] 3. Does the patient have a 15 day history of lactulose in the last 90 days? [If the answer to this question is no, then no further questions required.] Question 4. Is the dose less than or equal to 1,100mg per day? Circle Yes or No Y N Comments: I affirm that the information given on this form is true and accurate as of this date. Prescriber (Or Authorized) Signature Prescriber (Or Authorized) Signature Date Date