CurrentCountyCarePolicy 5045.CC

Vyepti (eptinezumab-jjmr) Coverage for Chronic Migraine Prevention

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This guideline governs prior authorization for Vyepti under the Health Plan medical benefit for Medicaid members and establishes initial authorization, reauthorization, dosing, documentation, and coding requirements.

Policy Summary

PayerCountyCare

PolicyVyepti coverage for chronic migraine prevention

Policy CodePolicy 5045.CC

Change TypeMaterial revision

Effective DateMarch 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit documentation meeting all applicable initial or reauthorization criteria.

SourceLink

POLICY UPDATE CHANGES

Removed prerequisite requirements for anticonvulsants, antidepressants, beta blockers, Botox, and calcium channel blockers.

Added a manufacturer-label dosing requirement to reauthorization criteria.

Clarified authorization duration of up to one year.

≥15Headache days per month

≥8Migraine days per month

2Preferred agents required

1 year

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CurrentCountyCarePolicy 5045.CC

Vyepti (eptinezumab-jjmr) Coverage for Chronic Migraine Prevention

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Policy Summary

PayerCountyCare

PolicyVyepti coverage for chronic migraine prevention

Policy CodePolicy 5045.CC

Change TypeMaterial revision

Effective DateMarch 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit documentation meeting all applicable initial or reauthorization criteria.

SourceLink

POLICY UPDATE CHANGES

Removed prerequisite requirements for anticonvulsants, antidepressants, beta blockers, Botox, and calcium channel blockers.

Added a manufacturer-label dosing requirement to reauthorization criteria.

Clarified authorization duration of up to one year.

≥15Headache days per month

≥8Migraine days per month

2Preferred agents required

1 year

Initial authorization

J3032Vyepti HCPCS code

MedicaidLine of business

Coverage Criteria

Initial Therapy Criteria

Covered for initial therapy when ALL of the following are met.

Initial therapy

Prescriber and age: Vyepti is prescribed by or in consultation with a neurologist, and the member is 18 years of age or older.Age ≥18 years
Dosing: Vyepti is prescribed at a dose within the manufacturer's dosing guidelines listed in FDA-approved labeling, based on diagnosis, weight, and other applicable factors.Within FDA-approved manufacturer dosing guidelines
Chronic migraine diagnosis: The member has chronic migraine, defined by at least 15 headache days per month for at least 3 months and at least 8 migraine days per month for at least 3 months.≥15 headache days/month and ≥8 migraine days/month for ≥3 months
Preferred CGRP antagonist history: The member has documented trial and failure lasting at least 3 months or intolerance to at least two preferred CGRP antagonists: Aimovig, Ajovy, Emgality, or Qulipta.At least 2 agents; trial and failure ≥3 months or intolerance
CGRP antagonist combination: Vyepti is not used in combination with any other CGRP antagonist medication for prevention of chronic migraine.
Concurrent use with another CGRP antagonist for acute migraine attacks is acceptable.

Reauthorization Criteria

Covered for reauthorization when ALL of the following are met.

Reauthorization

Dosing: Vyepti is prescribed at a dose within the manufacturer's dosing guidelines listed in FDA-approved labeling, based on diagnosis, weight, and other applicable factors.Within FDA-approved manufacturer dosing guidelines
Documented clinical benefit
- Improvement in migraine frequency and severity.
- Reduction in migraine days.
- Reduced use of medications to manage acute migraine attacks.

Vyepti must not be used in combination with another CGRP antagonist for the prevention of chronic migraine. Exception: concurrent use of another CGRP antagonist for acute migraine attacks is acceptable.

Initial Therapy Criteria

Vyepti Initial Authorization

Initial authorization requires ALL of the following.

Vyepti initial authorization

Prescriber and age: Vyepti must be prescribed by or in consultation with a neurologist, and the member must be 18 years of age or older.Age ≥18 years
FDA-approved dosing: The prescribed dose must be within the manufacturer's dosing guidelines listed in FDA-approved labeling, based on diagnosis, weight, and other applicable factors.Within FDA-approved manufacturer dosing guidelines
Chronic migraine: The member must have a diagnosis of chronic migraine defined as at least 15 headache days per month for at least 3 months and at least 8 migraine days per month for at least 3 months.

Continuation Criteria

Vyepti Reauthorization

Reauthorization requires ALL of the following.

Vyepti reauthorization

Label-consistent dose: The prescribed dose must be within the manufacturer's dosing guidelines listed in FDA-approved labeling, based on diagnosis, weight, and other applicable factors.Within FDA-approved manufacturer dosing guidelines
Clinical response
- Improvement in migraine frequency and severity.
- Reduction in migraine days.

Coding and Clinical Thresholds

Applicable CodeHCPCS

J3032

Injection, eptinezumab-jjmr, 1mg

Headache-Day Threshold

Minimum headache daysAt least 15 headache days per month

Measurement periodHeadache frequency is measured per month

Required durationThe threshold must be documented for at least 3 months

Migraine-Day Threshold

Minimum migraine daysAt least 8 migraine days per month

Measurement periodMigraine frequency is measured per month

Required duration

Provider Submission Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Vyepti (eptinezumab-jjmr) under the Health Plan's medical benefit. Requests are reviewed against FDA-approved criteria and may be referred to a Medical Director when established criteria are not met, as required by the plan and request level.

Applies to practitioners involved in providing Vyepti.
The prior authorization process is intended to promote appropriate utilization and determine Medical Necessity.

Step Therapy

Preferred CGRP Antagonist Prerequisite

Before initial authorization, document a trial and failure of at least 3 months or intolerance to at least 2 preferred CGRP antagonists.

Preferred agents: Aimovig, Ajovy, Emgality, and Qulipta.

Vyepti Background

Vyepti (eptinezumab-jjmr) is a calcitonin gene-related peptide (CGRP) antagonist indicated for the preventive treatment of migraine in adults. This policy addresses preventive treatment for adults with chronic migraine, defined as at least 15 headache days per month and at least 8 migraine days per month, with each frequency documented for at least 3 months.

Migraine Definitions

Chronic Migraine

DefinitionChronic migraine is defined as 15 or more headache days per month

Headache-day thresholdAt least 15 headache days in a month

Additional policy criterionCoverage criteria also require at least 8 migraine days per month for at least 3 months

Episodic Migraine

DefinitionEpisodic migraine is defined as fewer than 15 headache days per month

Headache-day thresholdLess than 15 headache days in a month

Distinction from chronic migraine

Preferred Therapy Requirements

Step	Preferred CGRP antagonist options	Requirement
1	Aimovig; Ajovy; Emgality; Qulipta	Documented trial and failure lasting at least 3 months or intolerance to at least 2 preferred agents

Policy Summary

PayerCountyCare

PolicyVyepti coverage for chronic migraine prevention

Policy CodePolicy 5045.CC

Change TypeMaterial revision

Effective DateMarch 1, 2026

Next Review DateN/A

Key ActionObtain prior authorization and submit documentation meeting all applicable initial or reauthorization criteria.

SourceLink

On This Page

≥15 headache days/month and ≥8 migraine days/month for ≥3 months

Preferred CGRP antagonist trial: The member must have documented trial and failure lasting at least 3 months or intolerance to at least two preferred CGRP antagonists.At least 2 agents; trial and failure ≥3 months or intolerance

Preferred agents are Aimovig, Ajovy, Emgality, and Qulipta.

Preventive CGRP combination: Vyepti must not be used in combination with any other CGRP antagonist medication for prevention of chronic migraine.

Concurrent use with another CGRP antagonist for acute migraine attacks is acceptable.

Reduced use of medications to manage acute migraine attacks.

The threshold must be documented for at least 3 months

Preferred CGRP Antagonist Trial

Minimum trial durationAt least 3 months

Required agentsAt least two preferred CGRP antagonists must be tried

Qualifying outcomeThe trial must document failure or intolerance

Documentation Required

Initial Clinical Documentation

Submit documentation supporting the initial request, including the prescriber or consulting neurologist, member age, chronic migraine diagnosis, dosing, prior treatment history, and applicable clinical records.

The prescriber must be, or consult with, a neurologist.
Member must be 18 years of age or older.
Document chronic migraine with at least 15 headache days per month and at least 8 migraine days per month, each for at least 3 months.
Document the Vyepti dose within manufacturer dosing guidelines and FDA-approved labeling, based on diagnosis, weight, and other applicable factors.
Include trial and failure of at least 3 months or intolerance to at least 2 preferred CGRP antagonists.

Documentation Required

Reauthorization Documentation

For reauthorization, submit a recent prescriber chart note confirming dosing within manufacturer guidelines and documenting treatment response.

Document at least one of the following: improvement in migraine frequency and severity; reduction in migraine days; or reduced use of medications for acute migraine attacks.

Denial Risk

Initial Criteria Not Met

The initial request may be denied when the initial criteria are not met.

The request is not prescribed by, or in consultation with, a neurologist.
The member is younger than 18 years of age.
The requested dose is outside the manufacturer's dosing guidelines or FDA-approved labeling.
The diagnosis does not meet the chronic migraine definition of at least 15 headache days and at least 8 migraine days per month, each for at least 3 months.
Documentation of the required trial and failure or intolerance to at least 2 preferred CGRP antagonists is missing or insufficient.

Denial Risk

Prohibited Preventive CGRP Combination

Vyepti must not be used in combination with another CGRP antagonist medication for prevention of chronic migraine.

Concurrent use with another CGRP antagonist is acceptable when the other agent is being used for acute migraine attacks.

Denial Risk

Continuation Criteria Not Met

Reauthorization may be denied when the requested dose is outside manufacturer dosing guidelines or when the prescriber does not document an adequate treatment response.

Submit a recent prescriber chart note.
Document dosing consistent with the FDA-approved labeling and manufacturer guidelines.
Document at least one response: improvement in migraine frequency and severity, reduction in migraine days, or reduced use of medications for acute migraine attacks.

The threshold is below 15 headache days per month