September 12, 2025

Effective October 1, 2025, the Medical Assistance Program will no longer cover Xifaxan 550 mg tablet due to the drug manufacturer no longer participating in the Medicaid Drug Program. Xifaxan 550 mg tablet will not be eligible for approval through prior authorization. Xifaxan 200 mg tablet will be eligible for approval through prior authorization for patients with a diagnosis of hepatic encephalopathy.

Affected Medications:

Xifaxan 550 mg tablet  - Not eligible for approval through prior authorization

Xifaxan 200 mg tablet  - Prior authorization required; approvable for a diagnosis of hepatic encephalopathy (HE) only

For the most up-to-date information regarding our formularies, please visit our Formularies page. For more information, call our Pharmacy department at 215-991-4300 or our Provider Services Helpline at 1-888-991-9023 (Monday to Friday, 9 a.m. to 4:30 p.m.). Thank you for your cooperation in improving the quality of care you deliver to your patients and our members.