SalivaMax — Highmark
dry mouth due to medication, disease, or other causes
Preferred products
- XyliMelt
- Natrol Dry Mouth Relief
- Biotene Mouthwash
- Crest Pro-Health Rinse
- Eco-Dent Daily Rinse
- Oasis Moisturizing Mouthwash
- Caphosol
- aluminum hydroxide solution
- Amphojel
- Zilactin
- Anbesol
- viscous lidocaine containing product
Initial criteria
- Member has experienced therapeutic failure, contraindication, or intolerance to all of the following plan-preferred products depending on indication
- For dry mouth due to medication, disease, or other causes, member has experienced therapeutic failure, contraindication, or intolerance to all of the following (i. through iv.):
- i. A saliva stimulating agent (for example, XyliMelt, Natrol Dry Mouth Relief)
- ii. An alcohol-free mouth rinse (for example, Biotene Mouthwash, Crest Pro-Health Rinse, Eco-Dent Daily Rinse, Oasis Moisturizing Mouthwash)
- iii. Caphosol
- For adjunct treatment of mucositis caused by radiotherapy or chemotherapy, member has experienced therapeutic failure, contraindication, or intolerance to all of the following (i. through iv.):
- i. An over the counter antacid agent (for example, aluminum hydroxide solution, Amphojel)
- ii. An over the counter film forming agent or benzocaine product (for example, Zilactin, Anbesol)
- iii. A viscous lidocaine containing product
- iv. Caphosol
Reauthorization criteria
- Exception to some or all criteria may be granted based on state and/or federal regulations
Approval duration
12 months