Can a hospital pharmacy deny a patient rifaximin (Rifaximin) prescribed at discharge and should the patient pay out of pocket to get insurance approval?

Hospital Pharmacy Denial of Rifaximin at Discharge

The facility pharmacy cannot legally deny a medically appropriate discharge prescription for rifaximin, but insurance authorization barriers are common and should be proactively addressed by the clinical team—not paid for out-of-pocket by the patient—through prior authorization submission with clinical documentation. 1

Understanding the Authorization Process

The issue you're facing is not about pharmacy "denial" but rather insurance coverage barriers that require prior authorization (PA). This is a systemic problem with rifaximin and similar specialty medications:

• All rifaximin prescriptions are typically covered by insurance once proper authorization is obtained 1
• Approximately 27% of rifaximin discharges require prior authorization, but all are approved when clinical documentation is submitted 1
• It is the joint responsibility of the clinical team (provider, case management, pharmacist) to ensure PAs are completed prior to discharge—not the patient's financial burden 1

Your Action Plan

Immediate Steps:

• Contact a transitions-of-care (TOC) pharmacist or hospital pharmacist immediately to submit the prior authorization with clinical notes and supporting literature 1
• The authorization can be overturned upon submission of clinical documentation, as demonstrated in cases where initial denials were reversed by pharmacist intervention 1
• Do not have the patient pay out-of-pocket while awaiting authorization—this creates unnecessary financial burden and delays appropriate therapy 1

Documentation to Include in PA:

• Specific indication for rifaximin (hepatic encephalopathy, irritable bowel syndrome with diarrhea, or travelers' diarrhea) 2, 3, 4
• Clinical notes demonstrating medical necessity
• Supporting literature if needed for off-label uses 1

Cost Considerations After Authorization

Once authorization is approved, copayments are typically manageable:

• 93% of patients have copayments of $50 or less across all payer groups 1
• Medicaid patients typically have minimal copayments ($0-$5) once authorized 1
• Commercial insurance patients can use manufacturer savings coupons to reduce copayments to $50 if needed 1
• Medicare patients may face higher copayments (5-25% of drug cost) depending on formulary tier, but most (83%) still have copayments under $50 1

Common Pitfalls to Avoid

• Never discharge a patient with a pending authorization without a backup plan—consider bridging with an alternative medication (such as oral vancomycin for hepatic encephalopathy) until rifaximin is approved 1
• Do not assume the patient should pay out-of-pocket—this violates the standard of care where the clinical team ensures medication access 1
• Delays in local pharmacy acquisition can occur—confirm the outpatient pharmacy can obtain the medication before discharge 1
• Avoid switching to less effective alternatives solely due to authorization delays when the clinical team can resolve the issue with proper documentation 1

Professional Standards

The medical team has a responsibility to ensure patients receive prescribed medications at discharge, which includes navigating insurance barriers through proper authorization processes rather than creating financial hardship for patients 1. Pharmacist-led anticoagulant and medication stewardship programs demonstrate that clinical pharmacists play a vital role in optimizing medication access for hospitalized patients 1.