CurrentmhnPolicy CP.PMN.302

Clinical Policy: Aceclidine (Vizz)

Clinical policy governing medical necessity and prior authorization criteria for aceclidine ophthalmic solution (Vizz) for treatment of presbyopia for Centene-affiliated health plans.

Policy Summary

Payermhn

PolicyClinical Policy: Aceclidine (Vizz)

Policy CodePolicy CP.PMN.302

Change TypeNo material changes

Effective Date12.01.25

Next Review Date

Key ActionSubmit prior authorization with documentation showing diagnosis of presbyopia, provider specialty, age 45-75 at initiation, failure of corrective lenses unless contraindicated, no concurrent Vuity/Qlosi, and dose ≤2 drops/eye/day.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

45-75age range for initial therapy eligibility

1.44%product concentration

2 drops/eye/daymaximum daily dosing

12 monthsapproval duration

Coverage Criteria

Initial Therapy - Presbyopia

Policy Summary

Payermhn

PolicyClinical Policy: Aceclidine (Vizz)

Policy CodePolicy CP.PMN.302

Change TypeNo material changes

Effective Date12.01.25

Next Review Date

SourceLink

On This Page

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Presbyopia initial criteria: 1. Diagnosis of presbyopia; 2. Prescribed by or in consultation with an optometrist or ophthalmologist; 3. Age between 45 and 75 years at the time of therapy initiation; 4. Failure of corrective eyeglasses or contact lenses to resolve the presbyopia symptoms unless contraindicated or clinically significant adverse effects are experienced; 5. Vizz is not prescribed concurrently with Vuity or Qlosi; 6. Dose does not exceed 2 drops per eye per day.

Approval duration: 12 months

Continued Therapy - Presbyopia

Covered when ALL of the following are met for Continued Therapy:

Presbyopia continued therapy criteria: 1. Member meets one of the following (a or b): a. Currently receiving medication via Centene benefit or member has previously met initial approval criteria; b. Member is currently receiving medication and is enrolled in a state and product with continuity of care regulations; 2. Member is responding positively to therapy; 3. If request is for a dose increase, new dose does not exceed 2 drops per eye per day.

Approval duration: 12 months

Other diagnoses/indications

Other diagnoses/indications:

Other indications pathway: 1. If the drug has undergone a label change within the last 6 months that is not yet reflected in this policy, refer to the applicable no-coverage or non-formulary policy for the relevant line of business (commercial, health insurance marketplace, or Medicaid) as listed in the policy; OR 2. If the requested use (diagnosis, age, dosing regimen) is not listed under the policy's exclusions and criterion 1 does not apply, refer to the off-label use policy for the relevant line of business.

See referenced policies: CP.CPA.190, HIM.PA.33, CP.PMN.255, HIM.PA.103, CP.PMN.16, CP.CPA.09, HIM.PA.154, CP.PMN.53

Provider Actions & Authorization Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Vizz. Providers must obtain prior authorization and submit documentation demonstrating that all approval criteria are met, including diagnosis, treating provider specialty, patient age, prior therapy attempts (step therapy), dosing, and absence of contraindicated concurrent medications.

Prior authorization required for Vizz (CP.PMN.302).
Ensure submission includes evidence of diagnosis, provider specialty, patient age, prior corrective eyewear/contact lens failure (or contraindication), medication dosing, and statement re: concurrent use with Vuity®/Qlosi™.
Approval duration: 12 months.

Step Therapy

Step Therapy Requirement

Step therapy applies: members must have tried and failed corrective eyeglasses or contact lenses for presbyopia prior to approval of Vizz, unless there is a documented contraindication or clinically significant adverse effect that prevents their use. Note: For Illinois HIM requests, the step therapy requirement does not apply effective 01/01/2026 per IL HB 5395.

Step therapy: documented failure of corrective eyeglasses/contact lenses required prior to Vizz approval unless contraindicated.
IL exception: IL HB 5395 removes step therapy for Illinois HIM requests as of 2026-01-01.

Documentation Required

Required Documentation

Providers must submit office chart notes, relevant diagnostic test results, and any other clinical information that supports the member meets ALL policy criteria. Missing or incomplete documentation may result in denial of the prior authorization request.

Required documentation: office/clinic notes, diagnostic test results, date of birth to confirm age, documentation of prior corrective eyewear/contact lens trial or contraindication, medication dosing, and prescriber specialty/consultation notes.
If documentation is not provided or does not demonstrate all required criteria, the request may be denied or returned for additional information.

Denial Risk

Documentation Triggers and Denial Risk

Documentation triggers — requests lacking required documentation or failing to show that approval criteria are met will be subject to denial. Examples include absence of documentation of failed corrective eyewear/contact lens therapy (or contraindication), missing prescriber specialty, patient age outside 45–75 years, evidence of concurrent Vuity® or Qlosi™ use, or dosing above 2 drops per eye per day.

Denial risk if: no proof of prior corrective eyewear/contact lens failure and no contraindication documented.
Denial risk if: prescriber is not an optometrist/ophthalmologist or consultation documentation is missing.
Denial risk if: patient age <45 or >75 at therapy initiation.
Denial risk if: concurrent prescription of Vuity® or Qlosi™ is noted.
Denial risk if: dosing exceeds 2 drops per eye per day.

OpenPayer

Clinical Policy: Aceclidine (Vizz)

Coverage Criteria

Provider Actions & Authorization Requirements

Definitions / Product Details

Background