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: Apr 24, 2026

Blue Cross Blue Shield of Arkansas - Pharmacy Prior Authorization Form Arkansas Blue Cross Blue Shield · Updated Apr 24, 2026

Blue Cross of Idaho - General Prior Authorization Form Blue Cross of Idaho Health Services, Inc. · Updated Apr 24, 2026

California - Uniform Prior Authorization FormCalifornia · Updated Apr 16, 2026

CDPHP - General Prior Authorization FormCapital District Physicians Health Plan, Inc. · Updated Apr 24, 2026

Cigna - General Medication Prior Authorization FormCigna Corporation · Updated Apr 24, 2026

Colorado - Uniform Prior Authorization FormColorado · Updated Apr 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

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.

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