Evoxac (cevimeline) — Highmark
Dry mouth in patients with Sjögren’s Syndrome
Preferred products
- generic pilocarpine
- generic cevimeline
Initial criteria
- The member has a diagnosis of Sjögren’s Syndrome (Sicca Syndrome) (ICD-10: M35.0)
- The member is experiencing symptoms of dry mouth
- 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, intolerance, or contraindication 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