Xifaxan Prior Authorization Resources

Find the right PA form for your patient's payer, get the ICD-10 codes you need, and download appeal templates — all in one place.

Last verified: May 11, 2026

Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield · Updated May 11, 2026
Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc. · Updated May 11, 2026
California - Uniform Prior Authorization FormCalifornia · Updated May 16, 2026
CDPHP - General Prior Authorization FormCapital District Physicians Health Plan, Inc. · Updated May 11, 2026
Cigna - General Medication Prior Authorization FormCigna Corporation · Updated May 11, 2026
Colorado - Uniform Prior Authorization FormColorado · Updated May 16, 2026

ICD-10 codes for Xifaxan Prior Authorizations

A09Infectious gastroenteritis and colitis, unspecified
A04.9Bacterial intestinal infection, unspecified
K72.90Hepatic failure, unspecified without coma
K72.11Chronic hepatic failure with coma
K58.0Irritable bowel syndrome with diarrhea

Appeal Templates

If the payer denies coverage, these templates help you build a stronger appeal.
Letter of Medical NecessityLetter of Medical Necessity resource
A peer-to-peer review with the payer's medical director can often resolve denials faster than a formal appeal.

Brand Resources

Tier Exemption RequestTier Exemption Request resource
PA Considerations PA Considerations resource
Formulary Information: Irritable Bowel Syndrome with DiarrheaFormulary Information: Irritable Bowel Syndrome with Diarrhea resource
Coverage Authorization Request: Irritable Bowel Syndrome with DiarrheaCoverage Authorization Request: Irritable Bowel Syndrome with Diarrhea resource
Formulary Information: Hepatic EncephalopathyFormulary Information: Hepatic Encephalopathy resource
Coverage Authorization Request: Hepatic EncephalopathyCoverage Authorization Request: Hepatic Encephalopathy resource

Support for Getting Your Patient on Xifaxan

Check coverage & formulary statusVerify PA requirements for your patient's plan.Find savings programsCopay cards, patient assistance, and more.Check medication interactionsScreen prescriptions for harmful drug combinations.