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SalivaMax — United Healthcare

oral mucositis

Initial criteria

  • EITHER (Diagnosis of xerostomia AND History of failure or contraindication to both of the following: saliva stimulants (e.g. sugar-free hard candies or gum) AND two OTC saliva substitutes (e.g. Biotene, Mouth Kote, Oasis, SalivaSure, Salivea); document name and duration of trial)
  • OR (Diagnosis of oral mucositis AND History of failure or contraindication to both of the following: topical lidocaine AND salt and sodium bicarbonate rinse)

Reauthorization criteria

  • Documentation of a positive response to therapy

Approval duration

12 months