CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Vyepti (eptinezumab-jjmr) intravenous for migraine prevention

Coverage and utilization management policy for Vyepti (eptinezumab-jjmr) IV for preventative treatment of migraine for Medicaid, Commercial, and Medicare-Medicaid Plan (MMP) members, including dosing limits, approval/renewal criteria, billing codes, and covered diagnosis codes.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVyepti (eptinezumab-jjmr) intravenous for migraine prevention

Policy CodePolicy N/A

Change TypeClarified scope and dosing/quantity limits

Effective DateJan 4, 2024

Next Review Date

Key ActionPrescriber must supply documentation of diagnosis, baseline objective severity measure (HIT-6/MPFID/diary), prior trials and treatment response evidence as required for initial approval and renewal.

POLICY UPDATE CHANGES

Policy scope lists applicability to Medicaid, Commercial, and Medicare-Medicaid Plan (MMP).

Dosing limits and quantity limits specified as 3 vials per 84 days and 300 billable units every 84 days.

6 monthsLength of authorization

3 vials/84 daysNDC quantity limit

J3032HCPCS code

≥50%Renewal response threshold

Scope: Policy covers Vyepti (eptinezumab-jjmr) intravenous for preventive treatment of migraine for Medicaid, Commercial, and Medicare-Medicaid Plan (MMP) members with utilization management. Status: CURRENT. Subject: Vyepti (eptinezumab-jjmr) intravenous for migraine prevention. Effective date: 01/04/2024; Last review: 01/08/2025. Length of authorization: 6 months with renewal criteria applied. Dosing/quantity limits in policy include a quantity limit of 3 vials per 84 days for Vyepti 100 mg/mL and HCPCS/coverage units of 100 billable units every 84 days for 100 mg (with option for 300 billable units every 84 days for 300 mg). Coverage stance: covered with criteria requiring initial and renewal criteria and documentation (e.g., diagnosis, baseline objective severity measure, prior trials, and documented treatment response).

Universal Criteria (Initial & Renewal)

Universal Criteria (applies to initial and renewal)

ALL of the following must be met:

ALL of the following

Other causes of headaches have been ruled out
Vyepti is not used in combination with other prophylactic CGRP antagonists
Baseline disease severity assessed with an objective measure/tool (e.g., HIT-6, MPFID, headache diary)
Continuation of other prophylactic interventions as appropriate

Provider Actions & Authorization Requirements

Prior Authorization

Prior authorization required with documentation

Prescriber must submit prior authorization with documentation to support diagnosis, baseline severity, prior trials, and treatment response for initial approval and renewal.

Diagnosis (ICD-10 codes for migraine as listed in Appendix 1)
Baseline objective severity measure (HIT-6, MPFID, or headache diary)
Prior trials: at least two oral migraine preventive medications from two different classes (3 months each)
Prior trials: documented inadequate response to at least two preferred injectable CGRP inhibitors (minimum 12 weeks each) — (MMP members: one formulary CGRP required)
For chronic migraine: documented inadequate response to at least two quarterly botulinum toxin injections (minimum 6 months) with documentation of clinical response
Evidence of treatment response as required for initial approval and for renewal (see renewal documentation criteria)

Billing Rule

Quantity / dosing limits

Quantity and dosing limits per policy/billing guidance.

Limit of 3 vials of Vyepti 100 mg/mL solution SDV per 84 days (NDC quantity limit)
Alternatively: 100 billable units every 84 days for the 100 mg dose
Or: 300 billable units every 84 days for the 300 mg dose

Billing Rule

Administration frequency

Administration frequency and approval period information.

Vyepti is administered by intravenous infusion every 3 months (every 84 days)
Recommended dose: 100 mg IV every 3 months; some patients may benefit from 300 mg every 3 months per criteria
Length of authorization: coverage provided for six months and may be renewed

Documentation Required

Documentation of response for renewal

For renewal, provide documentation demonstrating clinical response using acceptable measures.

Headache diary or clinician attestation documenting ≥50% reduction in mean monthly headache days relative to pretreatment baseline
OR MIDAS improvement: reduction of ≥5 points when baseline MIDAS is 11–20 OR ≥30% reduction when baseline MIDAS is >20
OR MPFID improvement: reduction of ≥25 points
OR HIT-6 improvement: reduction of ≥2.5 points
Other clinically meaningful improvement on validated migraine-specific patient-reported outcome measures as documented by clinician

Applicable Codes

HCPCS / Billing code for drugHCPCSCovered

J3032

Injection, eptinezumab-jjmr, 1 mg

NDC / Quantity limitNDCCovered

Vyepti 100 mg/mL solution SDV

3 vials per 84 days (quantity limit)

Approval Coverage UnitsmixedCovered

100 mg	100 billable units every 84 days
300 mg	300 billable units every 84 days

Covered Diagnosis Codes (ICD-10)ICD-10Covered

G43.001	Migraine without aura, not intractable, with status migrainosus
G43.009	Migraine without aura, not intractable, without status migrainosus
G43.011	Migraine without aura, intractable, with status migrainosus
G43.019	Migraine without aura, intractable, without status migrainosus
G43.101	Migraine with aura, not intractable, with status migrainosus
G43.109	Migraine with aura, not intractable, without status migrainosus
G43.111	Migraine with aura, intractable, with status migrainosus
G43.119	Migraine with aura, intractable, without status migrainosus
G43.401	Hemiplegic migraine, not intractable, with status migrainosus
G43.409	Hemiplegic migraine, not intractable, without status migrainosus

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Clinical Evidence & Safety

Nasopharyngitis; hypersensitivityCommon adverse events reported in trials: nasopharyngitis and hypersensitivity

Background evidence: Vyepti is in the calcitonin gene-related peptide (CGRP) antagonist drug class and was evaluated in randomized, placebo-controlled trials (PROMISE-1 and PROMISE-2) for episodic and chronic migraine. Trials administered Vyepti by intravenous infusion every 3 months and demonstrated statistically significant reductions in mean monthly migraine days (MMD) for both episodic and chronic migraine, with reported reductions versus placebo at the 100 mg and 300 mg doses. Common adverse events reported in the trials included nasopharyngitis and hypersensitivity.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVyepti (eptinezumab-jjmr) intravenous for migraine prevention

Policy CodePolicy N/A

Change TypeClarified scope and dosing/quantity limits

Effective DateJan 4, 2024

Next Review Date

On This Page

OpenPayer

Vyepti (eptinezumab-jjmr) intravenous for migraine prevention

Coverage Summary

Initial Therapy Criteria

Universal Criteria (Initial & Renewal)

Continuation / Renewal Criteria

Provider Actions & Authorization Requirements

Applicable Codes

Clinical Evidence & Safety

Background & Definitions

Revision History