UnitedHealthcare - 2014 to Present
Xifaxan (rifaximin)
Drugs for Infections : Antibiotics
  • Step Therapy: ST_APPLIES
  • Mantle Cell Lymphoma:
    Duration: 1 plan year
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

    Marginal Zone Lymphoma, Waldenstrom Macroglobulinemia:
    Age Requirement: >= 18
    Duration: 1 year(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: No
    Duration of Reauthorization: N/A

  • Quantity Limit: limit maximum 2 EA PER 1 day(s)
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