CurrentAvMedPolicy Pub. 100-2

Vyepti (eptinezumab) prior authorization for migraine prevention

This form and policy govern medical prior authorization and step-edit requests for IV eptinezumab (Vyepti) for adults with episodic or chronic migraine for AvMed members; it describes required documentation, initial and reauthorization criteria, and administrative instructions for prescribers.

Policy Summary

PayerAvMed

PolicyVyepti (eptinezumab) prior authorization for migraine prevention

Policy CodePolicy Pub. 100-2

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for J3032 with documentation of diagnosis, required prior preventive medication trials, and prescriber signature.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+minimum member age for initial authorization

6 moinitial authorization duration

12 moreauthorization duration

2 classespreventive medication trial requirement

100 mg q3mrecommended dosing

Policy Summary

PayerAvMed

PolicyVyepti (eptinezumab) prior authorization for migraine prevention

Policy CodePolicy Pub. 100-2

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionObtain prior authorization for J3032 with documentation of diagnosis, required prior preventive medication trials, and prescriber signature.

SourceLink

On This Page

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Initial Authorization Criteria

Covered when ALL of the following are met for initial authorization (6 months):

Age and prescriber: Member is 18 years of age or older AND prescribing physician is or has consulted with a neurologist or pain specialist.

Diagnosis: Member has a diagnosis of episodic migraine OR chronic migraine as defined by the policy thresholds (see definitions).

Documentation (lab results, diagnostics, and/or chart notes) must be provided to support the diagnosis.

Prior preventive medication trials: Member must have failed a 2-month trial of at least TWO migraine prophylactic medication classes (anticonvulsants, beta blockers, antidepressants, candesartan) with trials verified by chart notes and/or pharmacy paid claims.2 classes

Candesartan requires prior authorization.

Prior CGRP or oral preventive agent trial: Member must have failed a 2-month trial of at least ONE of the specified CGRP or oral preventive agents ( Aimovig [erenumab], Emgality [galcanezumab], Ajovy [fremanezumab], Nurtec ODT [rimegepant], Qulipta [atogepant] ) with documented reason for failure and trial verification by chart notes and/or pharmacy paid claims.1 agent

Aimovig, Emgality and Ajovy require prior authorization; Ajovy approval requires trial and failure of both preferred agents per PA rules.

Medication overuse and combination therapy: Member has been evaluated for medication overuse headache (MOH) and, if diagnosed, a plan to taper the offending medication is in place; requested medication will not be used in combination with another injectable CGRP inhibitor or an oral CGRP inhibitor indicated for migraine prevention unless concurrent-use criteria with Botox are met and documented.

Concurrent use with Botox requires meeting additional failure/inadequate response criteria and documentation as specified in policy.

Reauthorization Criteria

Reauthorization covered when ALL of the following are met:

Continuation of initial criteria: Member continues to meet all initial authorization criteria.

Documentation must be provided.

Clinical response: Member has experienced a positive response to therapy, demonstrated by a reduction in headache frequency and/or intensity and decreased use of acute migraine medications (e.g., NSAIDs, triptans).

Documentation of response required (chart notes, headache diaries, or other clinical evidence).

Monitoring and combination therapy: Member continues to be monitored for medication overuse headache and is not using Vyepti in combination with another injectable or oral CGRP inhibitor indicated for migraine prevention unless allowed by documented concurrent-use criteria.

For continuation of concurrent use with Botox, submit documentation demonstrating further reduction in migraine days or severe migraine days compared to monotherapy per policy requirements.

Requests for eptinezumab (Vyepti) must not be used in combination with another injectable CGRP inhibitor (for example, Aimovig®, Ajovy®, Emgality®) or an oral CGRP inhibitor indicated for migraine prevention (for example, Nurtec® ODT, Qulipta™) unless the specific concurrent-use criteria in the policy are met and documented. Concurrent use with onabotulinumtoxinA (Botox®) may be considered only when the member meets the additional criteria for combined therapy — including documentation that combined therapy produced further reduction in overall migraine days or severe migraine days compared with monotherapy — and all supporting documentation is submitted.

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Initiation of therapy using manufacturer samples does not satisfy the step-edit or prior authorization requirements; documentation of an adequate trial as described in the policy must be provided. All requests must include complete, legible supporting documentation (chart notes, pharmacy paid claims) verifying prior preventive medication trials and reasons for failure. Incomplete or illegible request forms or missing required fields (including prescriber signature, diagnosis, dosing schedule and supporting documentation) may delay or result in denial of authorization.

Concurrent use rules described in this policy prohibit combining Vyepti with other injectable or oral CGRP inhibitors for migraine prevention unless the concurrent-use criteria are met and documented; concurrent use with Botox® has separate criteria and requires documentation of additional benefit from combination therapy.

Provider Actions, Documentation & Billing

Prior Authorization

Prior Authorization Required

Prior authorization is required for Vyepti (eptinezumab) IV (HCPCS J3032). Initial approvals are for 6 months; reauthorizations are for 12 months. Submit completed prior authorization form and supporting chart notes to avoid delay.

Drug: Vyepti (eptinezumab) IV — HCPCS J3032
Initial approval: 6 months
Reauthorization: 12 months
Submit via fax: 1-877-535-1391

Step Therapy

Step Therapy and Concurrent Therapy Rules

Step therapy and concurrent therapy requirements must be documented. Members must have failed specified preventive medication classes and prior CGRP trials before approval. Vyepti must not be used concurrently with another injectable CGRP inhibitor or an oral CGRP inhibitor for migraine prevention unless concurrent-use criteria below are met. Concurrent use with Botox® has additional trial requirements.

Required failures of two prophylactic classes (2-month trial each): anticonvulsants, beta blockers, antidepressants, or candesartan (candesartan requires prior authorization).
Required failure of at least one prior CGRP preventive therapy (e.g., Aimovig, Emgality, Ajovy, Nurtec ODT, Qulipta) — trials must be documented; some agents require prior authorization.
For concurrent use with another CGRP inhibitor: generally not allowed. Concurrent use with Botox® permitted only if member meets ALL criteria including continued ≥4 migraine days/month after prior therapies and inadequate response to prior CGRP or Botox trials as specified.
Aimovig, Emgality, and Ajovy require PA; member must have tried and failed BOTH preferred agents and meet PA criteria for Ajovy.

Documentation Required

Required Form Fields & Supporting Documentation

Prescriber must complete all required form fields and include supporting documentation. Incomplete submissions may be delayed or denied.

Required form fields: prescriber printed name and signature (no preprinted stamps), prescriber NPI, office contact, phone and fax, member name, AvMed ID, DOB, diagnosis and ICD code, dosing schedule, length of therapy, weight (if applicable) and date weight obtained.
Supporting documentation: chart notes verifying migraine frequency (headache days and migraine days), prior medication trials and durations, reasons for failure/intolerance, pharmacy paid claims if available, Botox and CGRP trial documentation when applicable.

Denial Risk

Incomplete or Illegible Documentation

Authorization may be delayed or denied if the request form or supporting documentation is incomplete, incorrect, or illegible. Ensure all fields are completed and legible and include chart notes and evidence of prior medication trials.

Unsigned or stamped prescriber signature is not acceptable.
Missing phone/fax or incorrect member identifiers can delay processing.
Illegible or incomplete chart notes may result in denial.

Denial Risk

Insufficient Medication Trial Documentation

Requests lacking documentation of required prior medication trials or reasons for failure may be denied. Verify and include trial durations, specific agents, and documented reasons for discontinuation or inadequate response.

Document 2-month trials for required prophylactic classes and at least one prior CGRP preventive therapy where applicable.
Provide chart notes and/or pharmacy paid claims to verify trials and failure/intolerance.
For Botox or concurrent CGRP considerations, provide documentation of inadequate response to specified Botox or CGRP trials per criteria.

Definitions

Episodic migraine

DefinitionEpisodic migraine is defined as < 15 headache days per month AND 4 to 14 migraine days per month for a minimum of 3 months.

Documentation requirementAll documentation (lab results, diagnostics, and/or chart notes) supporting each line must be provided or request may be denied.

Related prior therapy requirementMember must have failed a 2-month trial of at least TWO migraine prophylactic classes (verified by chart notes and/or pharmacy paid claims).

Chronic migraine

DefinitionChronic migraine is defined as > 15 headache days per month AND > 8 migraine days per month for a minimum of 3 months.

Documentation requirementAll documentation (lab results, diagnostics, and/or chart notes) supporting each line must be provided or request may be denied.

Related prior therapy requirementMember must have failed a 2-month trial of at least TWO migraine prophylactic classes (verified by chart notes and/or pharmacy paid claims).

Medication overuse headache (MOH)

MOH definitionMedication overuse headache (MOH) is defined as headaches occurring greater than or equal to 15 days per month that develop as a consequence of regular overuse of acute or symptomatic headache medication for more than 3 months.

Evaluation requirementMember must be evaluated for MOH; if diagnosed, treatment must include a plan to taper off the offending medication.

Concurrent therapy restrictionRequested medication will NOT be used in combination with another injectable CGRP inhibitor or an oral CGRP inhibitor indicated for migraine prevention unless policy-specified concurrent-use criteria are met.

OpenPayer

Vyepti (eptinezumab) prior authorization for migraine prevention

Coverage Criteria for Vyepti (eptinezumab)

Coding and Clinical Thresholds

Provider Actions, Documentation & Billing

Background

Definitions