Evoxac (cevimeline) — Highmark
Dry mouth due to radiation therapy for head and neck cancer
Preferred products
- generic pilocarpine
- generic cevimeline
Initial criteria
- The member has a diagnosis of head and neck cancer
- The member is experiencing symptoms of dry mouth associated with radiation therapy
- If the request is for brand Evoxac, the member meets all of the following (a and b):
- a. The member has experienced therapeutic failure or intolerance to generic cevimeline
- b. The member has experienced therapeutic failure, contraindication, or intolerance to the plan-preferred generic pilocarpine
Reauthorization criteria
- The prescriber attests that the member has experienced positive clinical response to therapy
- If the request is for brand Evoxac, the member has experienced therapeutic failure or intolerance to generic cevimeline
Approval duration
12 months