Centene Vyepti Coverage Prior Auth Policy Update

Coverage and Medical Necessity Criteria

Initial Therapy

Covered when ALL of the following are met:

Initial Migraine Prophylaxis: 1. Diagnosis of episodic or chronic migraine; 2. Provider's attestation that member experiences ≥ 4 migraine days per month for at least 3 months; 3. Age ≥ 18 years; 4. Failure of at least 2 oral migraine preventive therapies from different therapeutic classes, each for 8 weeks unless clinically significant adverse effects or contraindications (examples: antiepileptics, beta-blockers, antidepressants); 5. Failure of Aimovig and Emgality unless clinically significant adverse effects or both are contraindicated; 6. Vyepti is not prescribed concurrently with other CGRP inhibitors (e.g., Aimovig, Ajovy, Emgality, Nurtec ODT, Qulipta, Ubrelvy, Zavzpret); 7. Dose does not exceed 100 mg once every 3 months.see nodes

Illinois-specific exemptions to step therapy noted in policy text.

Concurrent Botox Use

For members currently receiving Botox and requesting concurrent use (not switching), ALL of the following must be met:

Concurrent Botox and Vyepti: a. At least two high-quality published studies in peer-reviewed journals or evidence-based clinical practice guidelines are provided that address representative populations, drug regimen, and clinically meaningful outcomes (case reports and chart reviews are not acceptable); b. Member had ≥ 30% reduction in migraine days/month from baseline after at least 2 quarterly Botox injections (6 months) demonstrating positive response to Botox monotherapy; c. Despite Botox monotherapy, member continues to experience ≥ 4 migraine days/month and/or severe disabling migraines causing functional impairment.30% reduction

High-quality evidence required; case reports/chart reviews not acceptable.

Continuation Therapy

Covered when ALL of the following are met:

Continued Therapy - Migraine Prophylaxis: 1. Member currently receiving medication via Centene benefit or previously met initial approval criteria, or continuity of care applies; 2. Member has experienced and maintained positive response to therapy as evidenced by provider attestation of reduction in migraine days per month from baseline; 3. Vyepti is not prescribed concurrently with other CGRP inhibitors (e.g., Aimovig, Ajovy, Emgality, Nurtec ODT, Qulipta, Ubrelvy, Zavzpret); 4. If request is for dose increase, new dose must not exceed either: a) 100 mg once every 3 months, or b) 300 mg once every 3 months if medical justification for higher dose is provided.approval duration 12 months

Approval duration is 12 months.

Not Medically Necessary / Not Authorized

Not authorized:

Non-FDA or unlisted indications: Non-FDA approved indications not addressed in this policy are not authorized unless sufficient documentation of efficacy and safety is provided per off-label use policies (see HIM.PA.154) or evidence of coverage documents.none

Requests for off-label use require supporting evidence per policy.

Concurrent use and approval duration considerations

Policy requires prior authorization and applies restrictions on concurrent use

Concurrent therapy restriction and approval duration: Eptinezumab (Vyepti) requires prior authorization (HCPCS J3032 referenced in policy) and should not be prescribed concurrently with Botox or other CGRP inhibitors (including injectable, oral, or nasal products such as Zavzpret) unless supportive evidence from published studies or clinical practice guidelines is provided and the patient met criteria for a positive response to Botox monotherapy with continued migraine burden; initial and continuation approval durations have been adjusted over time and current approval duration is 12 months.

Policy history documents clarifications adding Zavzpret and modification of approval durations; Illinois-specific step therapy bypass noted.

This policy excludes concurrent prescription of eptinezumab-jjmr (Vyepti) with other CGRP inhibitors. Specifically, Vyepti must not be prescribed concurrently with other CGRP-targeted therapies (examples listed in the policy include Aimovig, Ajovy, Emgality, Nurtec ODT, Qulipta, Ubrelvy, and Zavzpret). Requests for indications that are non‑FDA approved and not addressed in this policy are not authorized unless the provider supplies sufficient documentation of efficacy and safety per the off‑label use policy (HIM.PA.154) or applicable evidence of coverage documents.

Concurrent prescribing of Vyepti with other CGRP inhibitors is restricted. The policy clarifies that Vyepti should not be prescribed concurrently with Botox or other CGRP products, and the list of CGRP agents has been explicitly updated to include Zavzpret. Prior authorization requirements and the policy’s concurrent‑use restrictions apply when other CGRP therapies are considered.

Use of eptinezumab for non‑FDA approved indications that are not specifically addressed in this policy is considered not authorized unless the request is supported by adequate documentation of safety and efficacy consistent with off‑label use procedures (see HIM.PA.154) or other evidence‑of‑coverage provisions.

Coding listed in this clinical policy is provided for informational purposes only. Inclusion or exclusion of any codes does not guarantee coverage; providers must consult the most up‑to‑date professional coding guidance prior to claim submission. The HCPCS code referenced for eptinezumab in this policy is J3032 (Injection, eptinezumab‑jjmr, 1 mg).

Billing and Coding

HCPCS CodesHCPCS

J3032

Injection, eptinezumab-jjmr, 1 mg

Referenced HCPCS CodesHCPCS

J3032

Injection, eptinezumab-jjmr, 1 mg

Maximum Dose — Policy Threshold

Maximum dose (policy threshold)300 mg every 3 months

Recommended typical dose100 mg IV every 3 months

Alternate higher dose noteSome patients may benefit from a dosage of 300 mg IV every 3 months

Dose frequencyEvery 3 months (q3 months)

Provider Requirements, Prior Authorization, and Documentation

Prior Authorization

Prior Authorization and Billing Code

Prior authorization is required per policy for eptinezumab (Vyepti). Providers must obtain PA prior to administration and reference applicable billing guidance. J3032 (Injection, eptinezumab-jjmr, 1 mg) is the HCPCS code referenced for billing; however, coding is informational and subject to professional coding guidance.

Prior authorization required for J3032 (eptinezumab)
Providers should verify most up-to-date coding guidance before claim submission

Denial Risk

Non-FDA Indications

Requests for indications that are not FDA-approved and not specifically addressed in this policy will be denied unless the provider supplies sufficient documentation supporting efficacy and safety consistent with Centene off-label use policies (e.g., HIM.PA.154) or other evidence of coverage documents.

Non-FDA indications require robust off-label evidence per Centene policy HIM.PA.154

Clinical Background

Eptinezumab‑jjmr (Vyepti) is a monoclonal antibody that targets the calcitonin gene‑related peptide (CGRP) pathway and is indicated for preventive treatment of migraine in adults. The recommended dosing regimen for migraine prophylaxis is 100 mg IV every 3 months, with the policy noting a maximum dosing consideration of up to 300 mg every 3 months in continued therapy when medically justified. The policy requires prior authorization (HCPCS code J3032 referenced) and defines clinical criteria for initiation and continuation of therapy, including age (≥ 18 years) and documented migraine frequency and prior preventive therapy trials.

Key Definitions

Migraine (PROMISE-I definition)

Duration of individual migraine episode (PROMISE‑I)Headache lasted 4–72 hours

Required headache features (at least two)Unilateral location; pulsating quality; moderate or severe intensity; or aggravation by/routine-activity avoidance (at least two required)

Associated symptoms (one or more)Nausea and/or vomiting; photophobia; phonophobia (one or more required)

Probable migraine definitionA qualifying headache with two of the three preceding criteria

Concurrent CGRP therapy — Definition and Policy Restriction

Definition of concurrent CGRP therapyUse of eptinezumab together with other CGRP inhibitors (injectable, oral, or nasal products such as Zavzpret) or with Botox

OpenPayer

Eptinezumab-jjmr (Vyepti) for migraine prophylaxis

Coverage and Medical Necessity Criteria

Billing and Coding

Provider Requirements, Prior Authorization, and Documentation

Clinical Background

Key Definitions