Pharmacy Prior Authorization Criteria

Vuity (pilocarpine) - PA, NF

Indications for Prior Authorization

Vuity (pilocarpine)

• For diagnosis of Presbyopia of the eye
  Indicated for the treatment of presbyopia in adults.

Criteria

Vuity

Prior Authorization (Initial Authorization)

Length of Approval: 1 Month(s)

• Diagnosis of presbyopia
AND
• Prescribed by or in consultation with ONE of the following:
• Ophthalmologist
• Optometrist
AND
• Provider confirms valid clinical rationale, which excludes lifestyle choice, as to why patient is unable to use corrective lenses (e.g., eyeglasses or contact lenses)

Vuity

Prior Authorization (Reauthorization)

Length of Approval: 6 Month(s)

• Patient demonstrates positive clinical response to therapy ( e.g., improvement in near vision in low light conditions without lost of distance vision)
AND
• Prescribed by or in consultation with ONE of the following:
• Ophthalmologist
• Optometrist

Vuity

Non Formulary

Length of Approval: 1 Month(s)

• Diagnosis of presbyopia
AND
• Prescribed by or in consultation with ONE of the following:
• Ophthalmologist
• Optometrist
AND
• Submission of medical records (e.g., chart notes) confirming valid clinical rationale, which excludes lifestyle choice, as to why patient is unable to use corrective lenses (e.g., eyeglasses or contact lenses)

P & T Revisions

2024-05-29, 2023-11-29, 2023-11-16, 2023-01-02, 2022-03-30, 2022-02-15, 2022-01-21

References

1. Vuity Prescribing Information. Abbvie Inc. North Chicago, IL. March 2023.

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Revision History

• 2024-05-29: update guideline
• 2023-11-29: 2024 Annual Review.
• 2023-11-16: Program update to standard reauthorization language. No changes to clinical intent.
• 2023-01-02: 2023 Annual Review
• 2022-03-30: Guideline Update
• 2022-02-15: Update Guideline
• 2022-01-21: 2022 New Um PA Criteria

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