Vypeti (eptinezumab-jjmr)

Coverage Summary

Vyepti (eptinezumab) is covered under the medical benefit for the preventive treatment of migraine in adults and requires prior authorization. This policy aligns with MassHealth and places Vyepti on the medical benefit (not the pharmacy benefit) with defined criteria for initial and continuation approvals.

Covered populationAdults ≥18

Minimum monthly migraine days≥ 4 days per month

Initial approval duration3 months

Reauthorization duration6 months

Benefit placementMedical benefit (prior authorization required)

Initial Therapy Criteria

ALL of the following

Member is ≥ 18 years of age
Indication: migraine prevention
Appropriate dose
Migraine frequency>= 4 days/month
Inadequate response or adverse reaction to ONE or contraindication to ALL of the following beta blockers:
- atenolol

Prior Authorization

Prior Authorization Required

Prior authorization required. Initial approvals will be granted for 3 months.

Prior authorization required for initiation of Vypeti (eptinezumab-jjmr).
Initial approval duration: 3 months.

Documentation Required

Documentation Requirements

Documentation required. Prescriber must document prior therapy trials or contraindications as part of the prior authorization request. For continuation, physician attestation of continued therapy and positive response is required.

Document trials (and dates) of one beta blocker trial (atenolol, metoprolol, nadolol, propranolol, or timolol) OR documented contraindication to ALL listed beta blockers.
Document trial (and dates) of one additional preventive agent (tricyclic antidepressant, topiramate, valproic acid, venlafaxine, or Botox) OR documented contraindication to ALL listed agents.
If prescriber documents a diagnosis of depression and specifically states they wish to avoid a β blocker for that reason, this is acceptable to bypass the beta blocker trial. Other accepted rationales for avoidance include asthma/bronchospastic disease, COPD, peripheral vascular disease, Raynaud's, baseline hypotension or bradycardia, and pheochromocytoma.
For reauthorization, include physician attestation of continuation of therapy and objective evidence of positive response (e.g., reduction in migraine days/month).

Continuation Therapy Criteria (Reauthorization)

Continuation of Therapy (Reauthorization)

Reauthorization requirements:

Physician attestation of continuation of therapy and positive response to therapy

Documentation Required

Reauthorization requires physician attestation — 6 months

For reauthorization, physician attestation of continuation of therapy and positive response is required. Reauthorizations are granted for 6 months.

Exceptions / New-to-plan Continuation

Exceptions / New-to-plan continuation

Authorizations for members new to the plan who are currently receiving treatment:

Authorization requests will be reviewed on a case-by-case basis for members new to the plan who are currently receiving treatment with the requested medication (excluding when product obtained as samples or via manufacturer's patient assistance programs)

Prior Authorization

Prior authorization — new-to-plan members reviewed case-by-case

Prior authorization is required for medical-benefit Vyepti. Requests for members new to the plan who are currently receiving Vyepti will be reviewed on a case-by-case basis.

Limitations, Concomitant Therapy & Exclusions

Concomitant use of injectable CGRP monoclonal antibodies (such as Vyepti) with oral CGRP antagonists for acute treatment is allowed. Data are limited on combining CGRP inhibitors with onabotulinumtoxinA (Botox); however, the policy notes that patients with a partial response to Botox may receive combined therapy with documentation and may be approved for a limited period. The plan removed Rx drugs from this policy while continuing medical-administered Vyepti on the medical benefit.

Applicable Codes

Medical benefit administered product (no specific codes listed in document)mixedCovered

No codes listed

Billing Rule

Benefit placement — medical benefit (other CGRP agents via pharmacy)

Benefit placement: Vyepti is managed on the medical benefit. Additional agents in the CGRP class may be available through the pharmacy benefit per the MassHealth Drug List.

Provider Actions & Documentation Requirements

Prior Authorization

Prior authorization required — initial 3 months; reauth 6 months

Prior authorization is required for Vyepti on the medical benefit. Initial approvals will be granted for 3 months and reauthorizations for 6 months — PA is required for initiation and continued therapy.

Documentation Required

Documentation: prior therapy trial requirements and allowable bypass

Documentation must show inadequate response or adverse reaction to one beta blocker and one additional agent, or document contraindication to ALL listed agents. Alternatively, the prescriber may document an acceptable reason to bypass the beta blocker trial per the policy definition (diagnosed depression or listed contraindications such as asthma/bronchospastic disease, COPD, peripheral vascular disease, Raynaud's, baseline hypotension or bradycardia, pheochromocytoma).

Document inadequate response/adverse reaction to ONE beta blocker (atenolol, metoprolol, nadolol, propranolol, timolol).

Clinical Evidence & References

Prescribing information: Vyepti [prescribing information], Lundbeck Pharmaceuticals LLC; Aug 2024.

Note: Background materials indicate limited data exist for combination therapy with Botox and CGRP inhibitors and retrospective analyses and expert consensus suggest possible benefit for partial responders, but no trial metrics are provided here.

Background

Vyepti (eptinezumab) is indicated for the preventive treatment of migraine in adults. This policy aligns with MassHealth coverage and places Vyepti on the medical benefit with prior authorization requirements. Initial authorization criteria define age (≥ 18 years), appropriate dose, and a migraine frequency threshold of ≥ 4 days per month, plus prior therapy trial or contraindication requirements. Reauthorization requires physician attestation of continued therapy and positive response, with initial approvals granted for 3 months and reauthorizations for 6 months. Concomitant therapy guidance notes that concomitant use with oral CGRP antagonists for acute treatment is allowed and that data are limited for combination with Botox; combined use may be considered in documented partial responders.

Bypass beta blocker trial: Acceptable rationale includes a documented diagnosis of depression or contraindications such as asthma/bronchospastic disease, COPD, peripheral vascular disease, Raynaud's, baseline hypotension or bradycardia, and pheochromocytoma.

Revision History

06/01/2025effectiveLatest

Effective 6/1/25: Updated formatting and references; removed Rx drugs while medical drugs will remain on this policy as Rx drugs are available on MHDL. (Review history entry 05/15/25)

06/30/2023administrative/coding alignment

Effective 6/30/23: Removed preferred product criteria from Vyepti (administrative/coding alignment).