Clinical Policy: Aceclidine (Vizz)
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Clinical policy governing medical necessity and prior authorization criteria for aceclidine ophthalmic solution (Vizz) for treatment of presbyopia for Centene-affiliated health plans.
No material clinical or coverage changes in this revision.
Coverage Criteria
Initial Therapy - Presbyopia
Covered when ALL of the following are met for Presbyopia:
Approval duration: 12 months
Continued Therapy - Presbyopia
Covered when ALL of the following are met for Continued Therapy:
Approval duration: 12 months
Other diagnoses/indications
Other diagnoses/indications:
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
Requests for use of aceclidine (Vizz) for non‑FDA approved indications that are not specifically addressed in this policy are not authorized unless there is sufficient documentation of efficacy and safety per the applicable off‑label use policies for the member’s line of business.
Authorization for requests involving non‑FDA approved indications is contingent on submission of supporting clinical documentation that demonstrates efficacy and safety in accordance with the referenced off‑label use policies (see CP.CPA.09 for commercial, HIM.PA.154 for health insurance marketplace, and CP.PMN.53 for Medicaid) or the member’s evidence of coverage documents.
Provider Actions & Authorization Requirements
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 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.
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.
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.
Definitions / Product Details
Background
Aceclidine (Vizz) is a cholinergic agonist ophthalmic solution approved by the FDA for the treatment of presbyopia. It is supplied as a 1.44% ophthalmic solution in single‑dose vials. The dosing regimen is to instill 1 drop in each eye once daily, with the option to instill a second drop after 2 minutes if needed, for a maximum of 2 drops per eye per day.
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