I’m wondering what your experience has been in getting rifaximin covered by insurance or ways to make it more affordable. It seems like some patients have no problem and others have been unable to get it covered even when a diagnosis of IBS-D is used. I had one patient I prescribed it for where I had to do a pre-auth for it that included questions about whether or not she had even ever tried antidepressants before this condition. Because she hadn’t it was denied. So I was just wondering if you could talk through your process for best ways to get it covered and work around the system.

Chris Kresser:  Really good question, and yes, we’ve had the same struggles. Different insurance companies have different procedures for whether they approve it even when the diagnosis of IBS is used. Blue Cross Blue Shield in California, for example, makes you jump through a whole bunch of hoops. You have to have tried Imodium or other antidiarrheal meds and even then, I think if SSRIs or antidepressants haven’t been used, then they’ll typically deny it. So in those cases unless you’re willing to prescribe an antidepressant, which I definitely wouldn’t recommend, insurance coverage is probably not going to be possible. And it’s so ridiculous and it’s a huge problem because of the cost of that medication, and it’s why we’re really continuing to explore botanical and non-pharmaceutical treatment options. Rifaximin is very effective and it’s unfortunate that it’s so expensive and difficult to obtain. But there are the botanical protocol options and then other options like Atrantil, which is a relatively new supplement that was developed by a gastroenterologist that some patients are having success with, particularly with IBS-C or methane-predominant SIBO. And we just need to continue to work together to find better solutions and hope that the insurance reimbursement landscape for rifaximin will change as the awareness of SIBO increases and the amount of published literature around it proliferates, which it certainly is.