PRIOR AUTHORIZATION FORM: XIFAXAN® Please fax the completed form to CVS Caremark* at (855) 330-1721. Contact CVS Caremark at (855) 582-2038 with questions. Patient Information Last Name: First Name: Home Phone Number: Work Phone Number: Home Address: City: Date of Birth: Allergies: Insurance ID #: State:  NKA  Zip: Other: Group #: Physician Information MD Name: MD DEA #: NPI #: Address: City: State: Office Contact Name: Phone Number: Fax Number: Zip: Primary Diagnosis Primary ICD-9 (Code): Clinical Information 1. Quantity Requested: ________________________ per _________________ days for ___________________________________ strength (Quantity limit is 9 tablets per 34 days for 200mg strength and 68 tablets for 34 days for 550mg strength) 2. 3. His Xifaxan® being prescribed for traveler’s diarrhea caused by E. coli?  Yes  No  Yes  No ® His Xifaxan being prescribed for hepatic encephalopathy (HE) recurrence? ® If no, please specify diagnosis. (If Xifaxan is being prescribed for an off-label indication, please provide supporting literature for the diagnosis.) Physician Signature Required Information on this form is accurate as of this date: Signature: _____ / _____ / _____ CUT0377-1E (1/14) *CVS Caremark is an independent company that provides pharmacy benefit management services to CareFirst. CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association.