CurrentMass General Brigham Health PlanPolicy N/A

Calcitonin Gene-Related Peptide (CGRP) Inhibitors: Vyepti (eptinezumab-jjmr)

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This policy governs prior authorization and continuation of Vyepti (eptinezumab-jjmr) under the medical benefit for adult members receiving preventive treatment for migraine, including MassHealth UPPL coverage, clinical criteria, documentation, step therapy, and continuation requirements.

Policy Summary

PayerMass General Brigham Health Plan

PolicyVyepti (eptinezumab-jjmr) for migraine prevention

Policy CodePolicy N/A

Change TypeClinical criteria and reauthorization update

Effective DateJan 4, 202757d

Last ReviewNov 4, 2026

Next Review DateN/A

Key ActionDocument inadequate response or an adverse reaction to one of Aimovig, Ajovy, or Emgality, or a contraindication to all three.

SourceLink

POLICY UPDATE CHANGES

A step-through requirement with Aimovig, Ajovy, or Emgality was added for Vyepti requests.

The reauthorization approval duration was extended to 12 months.

3 monthsInitial approval

12 monthsReauthorization

≥18 yearsMinimum age

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CurrentMass General Brigham Health PlanPolicy N/A

Calcitonin Gene-Related Peptide (CGRP) Inhibitors: Vyepti (eptinezumab-jjmr)

Customize your policy alerts

Sign up for all Mass General Brigham Health Plan policy alerts

Know when Mass General Brigham Health Plan releases new policies or updates existing guidance.

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Policy Summary

PayerMass General Brigham Health Plan

PolicyVyepti (eptinezumab-jjmr) for migraine prevention

Policy CodePolicy N/A

Change TypeClinical criteria and reauthorization update

Effective DateJan 4, 202757d

Last ReviewNov 4, 2026

Next Review DateN/A

Key ActionDocument inadequate response or an adverse reaction to one of Aimovig, Ajovy, or Emgality, or a contraindication to all three.

SourceLink

POLICY UPDATE CHANGES

A step-through requirement with Aimovig, Ajovy, or Emgality was added for Vyepti requests.

The reauthorization approval duration was extended to 12 months.

3 monthsInitial approval

12 monthsReauthorization

≥18 yearsMinimum age

2 classesConventional therapy trials

1 agentCGRP therapy trials

Coverage Criteria

Initial or New-Member Coverage

Coverage may be authorized through either the new-member continuity pathway or when ALL applicable clinical criteria are met.

ONE of the following pathways

New-member continuity pathway
- Member is new to the plan, as evidenced by a coverage effective date of less than or equal to 90 days.
- Medical records document that the member is currently receiving treatment with the requested drug.
  Treatment obtained as samples or through a manufacturer's patient assistance program does not qualify.
Initial clinical criteria
- Indication of migraine prevention.
- Member is at least 18 years of age.
- Requested drug is prescribed at an appropriate dose.
- Migraine frequency is at least 4 days per month.>= 4 migraine days per month
- Inadequate response or adverse reaction to TWO, or contraindication to ALL, of the following: beta blocker; tricyclic antidepressant (TCA); topiramate; or valproate (valproic acid or divalproex).
  If the prescriber documents that a beta blocker is being avoided because of a concurrent diagnosis of depression, this is acceptable rationale to bypass the trial. Avoidance solely due to risk of depression without a documented diagnosis of depression is not adequate. Acceptable additional reasons to avoid beta blockers include asthma (bronchospastic disease), COPD, peripheral vascular disease, Raynaud's, baseline hypotension or bradycardia, and pheochromocytoma.
- Inadequate response or adverse reaction to ONE, or contraindication to ALL, of the following: Aimovig, Ajovy, or Emgality.

Reauthorization

Reauthorization requires physician attestation of continuation of therapy and positive response to therapy.

ALL of the following

Physician attestation documents continuation of therapy.
Member has demonstrated a positive response to therapy.
Reauthorization period is up to 12 months.12 months

Concomitant Oral CGRP Inhibitor Therapy

Concomitant use of an injectable CGRP inhibitor for migraine prophylaxis with an oral CGRP inhibitor for acute treatment is permitted.

ALL of the following

Requested therapy combines an injectable CGRP inhibitor for prophylaxis with an oral CGRP inhibitor for acute treatment.
Concomitant use is clinically appropriate based on the member's migraine treatment needs.

Botox Add-On Therapy

Botox may be added to CGRP inhibitor therapy when the provider documents a partial but incomplete response.

ALL of the following

Provider documents a partial, but incomplete, response to a CGRP inhibitor.
Provider documents the need to add Botox therapy to supplement the CGRP inhibitor.
Initial approval for the Botox add-on is limited to 3 months.3 months
For resubmission, documentation must demonstrate response to therapy and improvement in headache days per month.
Upon successful resubmission, therapy may be recertified for up to 6 months.

Coverage Parameters and Approval Durations

New-Plan Member Window

Coverage effective dateLess than or equal to 90 days

Member Age

Minimum member age18 years

Migraine Frequency

Required migraine frequencyAt least 4 days per month

Initial Approval Duration

Initial approval period

Provider Requirements and Denial Risks

Prior Authorization

Submit prior authorization under the medical benefit

Vyepti is subject to prior authorization under the MassHealth UPPL and is covered under the medical benefit.

Step Therapy

Document two conventional preventive-therapy trials

Document an inadequate response or adverse reaction to two conventional migraine-preventive therapies: a beta blocker, tricyclic antidepressant, topiramate, or valproate. A contraindication to all four therapies may be submitted instead.

Beta blocker
Tricyclic antidepressant (TCA)
Topiramate
Valproate, including valproic acid or divalproex

Therapy Background

Vyepti (eptinezumab) is a calcitonin gene-related peptide (CGRP) inhibitor indicated for the preventive treatment of migraine in adults. This policy addresses Vyepti continuation therapy under the medical benefit, including clinical eligibility, prior-treatment requirements, and documentation of response for reauthorization.

Policy Definitions

Inadequate Response, Adverse Reaction, or Contraindication

Unsuccessful treatment trialA treatment trial is considered unsuccessful when the member has an inadequate response or an adverse reaction; a contraindication to all agents in a required group may substitute for the specified trials.

Partial Response

Partial responseAn incomplete response to a CGRP inhibitor that may justify adding Botox to supplement treatment when the provider documents the response and subsequent improvement in headache days per month.

Policy Summary

PayerMass General Brigham Health Plan

PolicyVyepti (eptinezumab-jjmr) for migraine prevention

Policy CodePolicy N/A

Change TypeClinical criteria and reauthorization update

Effective DateJan 4, 202757d

Last ReviewNov 4, 2026

Next Review DateN/A

Key ActionDocument inadequate response or an adverse reaction to one of Aimovig, Ajovy, or Emgality, or a contraindication to all three.

SourceLink

On This Page

Reauthorization Duration

Reauthorization period12 months

Botox Add-On Approval

Initial approval3 months

RecertificationUp to 6 months

Step Therapy

Document the required CGRP inhibitor trial

Document an inadequate response or adverse reaction to one of Aimovig, Ajovy, or Emgality. A contraindication to all three agents may be submitted instead.

Aimovig
Ajovy
Emgality

Documentation Required

Document an accepted reason to avoid beta blockers

If bypassing a beta-blocker trial, document the accepted rationale. A concurrent diagnosis of depression is acceptable; other accepted reasons include asthma or bronchospastic disease, COPD, peripheral vascular disease, Raynaud's, baseline hypotension or bradycardia, and pheochromocytoma.

Avoidance due solely to risk of depression without a documented diagnosis of depression is not adequate rationale.
Document the applicable diagnosis or condition in the record.

Documentation Required

Submit continuity records for new-plan members

For members whose coverage effective date is less than or equal to 90 days, submit medical records documenting that the member is currently receiving Vyepti. Treatment obtained solely as samples or through a manufacturer's patient assistance program does not satisfy this requirement.

Documentation Required

Attest to continued therapy and positive response

For reauthorization, provide physician attestation that therapy is continuing and that the member has had a positive response to therapy.

Documentation Required

Document response when adding Botox

If Botox is added to supplement a partially responsive CGRP inhibitor, document the partial but incomplete response. Subsequent resubmission must document response to therapy and improvement in headache days per month; recertification may be granted for up to 6 months.

Initial add-on approval may be granted for 3 months.
Document improvement in headache days per month for resubmission.

Denial Risk

Meet all clinical criteria before submitting

Requests may be denied when the indication is not migraine prevention, the member is under 18, the dose is not appropriate, or migraine frequency is less than 4 days per month.

Indication: migraine prevention
Member age: at least 18 years
Appropriate dose
Migraine frequency: at least 4 days per month

Denial Risk

Avoid gaps in conventional preventive-therapy history

Requests may be denied when the member has not demonstrated an inadequate response or adverse reaction to two conventional preventive therapies, or a contraindication to all listed conventional therapies.

Required therapies include a beta blocker, tricyclic antidepressant, topiramate, and valproate.
Document two unsuccessful trials or contraindications to all four therapies.

Denial Risk

Document the required CGRP step therapy

Requests may be denied when the member has not demonstrated an inadequate response or adverse reaction to one of Aimovig, Ajovy, or Emgality, or a contraindication to all three.

Document the applicable unsuccessful trial or adverse reaction.
Alternatively, document a contraindication to Aimovig, Ajovy, and Emgality.

Denial Risk

Do not omit new-member continuity records

For members new to the plan, requests may be denied if medical records do not document current treatment with Vyepti or if the reported product was obtained only through samples or a manufacturer's patient assistance program.

Applies when the coverage effective date is less than or equal to 90 days.
Submit records confirming the member is currently receiving the requested drug.