CurrentNeighborhood Health Plan of Rhode IslandPolicy N/A

Vyepti (eptinezumab-jjmr) intravenous for migraine prevention

Policy governs coverage, clinical criteria, dosing, renewal, units, billing codes, and required trials for Vyepti for Medicaid, Commercial, and Medicare members of Neighborhood Health Plan of Rhode Island.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVyepti (eptinezumab-jjmr) intravenous for migraine prevention

Policy CodePolicy N/A

Change TypeNo material change

Effective Date07/01/2020

Next Review DateN/A

Key ActionPrescriber must document age, specialist involvement (or consultation), baseline objective measure (e.g., HIT-6/MIDAS/MPFID/MHD), prior trials and failures of specified oral prophylactics, injectable CGRPs, and botulinum toxin trials, and provide clinical response documentation as required.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes identified in this update.

18+Covered ages (years)

100 mg doseInitial dosing option

300 mg doseEscalation dosing option

300 unitsPolicy max units per 84 days

6Approval length (months)

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Coverage Summary

Scope: This policy governs coverage, clinical criteria, dosing, renewal, units, billing codes, and required prior trials for Vyepti (eptinezumab-jjmr) for Medicaid, Commercial, and Medicare members of Neighborhood Health Plan of Rhode Island. Coverage stance: covered_with_criteria (coverage provided when the policy's clinical criteria are met). Covered indication: preventive treatment of migraine in adults. Dosing cadence and administration: Vyepti is administered intravenously every 3 months with an initial dosing option of 100 mg and an escalation option to 300 mg if criteria are met. Covered ages and payer applicability: policy applies to members aged 18+ and to Medicaid, Commercial, and Medicare populations. Policy limits: maximum of 300 billable units every 84 days (100 units = 100 mg dose; 300 units = 300 mg dose).

Initial Therapy Criteria

Initial Approval Criteria

Coverage is provided when ALL of the following are met:

ALL of the following

ALL of the following
- Member must be 18 years or older
- Prescriber is a neurologist or headache specialist, or in consultation with a neurologist or headache specialist
- Universal Criteria
  - Other causes of headaches have been ruled out
  - Vyepti is not used in combination with other prophylactic calcitonin gene-related peptide (CGRP) antagonists (examples: Aimovig [erenumab], Ajovy [fremanezumab], Emgality [galcanezumab], Nurtec ODT [rimegepant], Qulipta [atogepant])
  - Member will continue to utilize prophylactic intervention modalities (i.e., pharmacotherapy, behavioral therapy, physical therapy, etc.)
  - Physician has assessed baseline disease severity utilizing an objective measure/tool (e.g., HIT-6; monthly headache day [MHD]; MIDAS; MPFID)
  - Member has been fully equipped with abortive migraine therapy, if appropriate, and has had inadequate relief
- Indication-specific (ONE of chronic migraine OR frequent episodic migraine)
  - Preventative Treatment of Chronic Migraines
    Member has a diagnosis of chronic migraines defined as 15 or more headache (tension-type-like and/or migraine-like) days per month for > 3 months
    Member has had at least five attacks with features consistent with migraine (with and/or without aura)
    On at least 8 days per month for > 3 months, headaches have characteristics and symptoms consistent with migraine OR suspected migraines are relieved by a triptan or ergot derivative medication
    Headaches have characteristics and symptoms consistent with migraine
    Member suspected migraines are relieved by a triptan or ergot derivative medication
- Members new to therapy must initiate treatment at the 100 mg dose before increasing to the 300 mg dose if required
- For Medicare members ONLY, failure of one formulary CGRP inhibitor is required (instead of two)

Continuation / Renewal Criteria

Provider Actions & Billing Requirements

Prior Authorization

Prior authorization required with documentation

Prescriber must provide documentation to support prior authorization, including patient age, involvement of a neurologist or headache specialist (or documentation of consultation), baseline objective measure of disease severity (e.g., HIT-6, MIDAS, MPFID, monthly headache days), prior trials and failures of specified oral prophylactics, prior trials and failures of preferred injectable CGRP inhibitors and botulinum toxin as required by indication, and documentation of clinical response (baseline and follow-up measures) as applicable.

Age (must be ≥18 years)
Prescriber is a neurologist/headache specialist or consultation noted
Baseline objective measure (HIT-6, MIDAS, MPFID, or monthly headache days)
Prior trials and failures of two oral prophylactic medications (3 months each)
Prior trials and failures of two preferred injectable CGRP inhibitors (≥12 weeks each) when required
Prior trials and failures of botulinum toxin (two quarterly injections = 6 months) when required
Documentation of clinical response or inadequate response (change in frequency, duration, severity; validated PROs or headache diary)

Applicable Codes

HCPCS (billing unit)HCPCSCovered

J3032

Injection, eptinezumab-jjmr, 1 mg

NDCNDCCovered

67386-0130-xx

Vyepti 100 mg/mL solution for injection; single-dose vial

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

1–10 of 20

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Clinical Evidence

100 mg -3.9 dPROMISE-1 (episodic migraine): 100 mg reduced MMD by 3.9 days; 300 mg reduced MMD by 4.3 days vs placebo

300 mg -4.3 dPROMISE-1 (episodic migraine): 100 mg reduced MMD by 3.9 days; 300 mg reduced MMD by 4.3 days vs placebo

100 mg -7.7 dPROMISE-2 (chronic migraine): 100 mg reduced MMD by 7.7 days; 300 mg reduced MMD by 8.2 days vs placebo

300 mg -8.2 dPROMISE-2 (chronic migraine): 100 mg reduced MMD by 7.7 days; 300 mg reduced MMD by 8.2 days vs placebo

Vyepti is an intravenous calcitonin gene-related peptide (CGRP) antagonist with efficacy demonstrated in randomized, placebo-controlled trials for both episodic and chronic migraine. In the episodic migraine trial, the 100 mg dose reduced mean monthly migraine days (MMD) by 3.9 days and the 300 mg dose by 4.3 days versus placebo. In the chronic migraine trial, the 100 mg dose reduced MMD by 7.7 days and the 300 mg dose by 8.2 days. Both studies used IV administration every 3 months.

Background & Definitions

Background: Vyepti (eptinezumab-jjmr) is an intravenous CGRP antagonist indicated for the preventive treatment of migraine in adults. It is administered by intravenous infusion with a recommended dosage of 100 mg every 3 months, with some patients benefiting from a 300 mg every 3 months dose per the policy criteria.

Term	Definition
Chronic migraine
15 or more headache days per month for >3 months (tension-type-like and/or migraine-like)
Frequent episodic migraine
At least 5 headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
CGRP inhibitors (preferred injectable) examples
Examples include Aimovig (erenumab), Ajovy (fremanezumab), Emgality (galcanezumab)

Key thresholds & units

Renewal response thresholdReduction in mean monthly headache days ≥50% relative to pretreatment baseline

MIDAS thresholdsReduction ≥5 points when baseline MIDAS is 1-20 OR reduction ≥30% when baseline MIDAS >20

MPFID thresholdReduction of ≥5 points

HIT-6 thresholdReduction of ≥5 points

Dosage units / billing period100 billable units every 84 days for 100 mg dose; 300 billable units every 84 days for 300 mg dose

Revision History

2020-07-01effective

Policy effective date per document header (Effective Date: 07/01/2020).

2026-03-03last_reviewLatest

Most recent review date listed in document Dates Reviewed (03/03/2026); changes list in brief is empty.

Policy Summary

PayerNeighborhood Health Plan of Rhode Island

PolicyVyepti (eptinezumab-jjmr) intravenous for migraine prevention

Policy CodePolicy N/A

Change TypeNo material change

Effective Date07/01/2020

Next Review DateN/A

SourceLink

On This Page

Member has a documented inadequate response to a 3-month trial of two oral medications from two different classes of drugs for the prevention of migraines (see prophylactic medication list)

Member has a documented inadequate response to (or is unable to tolerate) a minimum trial of at least two quarterly injections (6 months) of a botulinum toxin and documentation of clinical response as demonstrated by change in headache frequency, duration and/or severity from baseline must be provided

Member has a documented inadequate response to (or is unable to tolerate) a minimum trial of at least 12 weeks to two preferred injectable CGRP inhibitors (examples: Aimovig, Ajovy, Emgality) and documentation of clinical response as demonstrated by change in headache frequency, duration and/or severity from baseline must be provided

Preventative Treatment of Frequent Episodic Migraines

Member has a diagnosis of frequent episodic migraines defined as at least 5 headache attacks lasting 4-72 hours (when untreated or unsuccessfully treated)
Headaches have characteristics and symptoms consistent with migraine without aura
Medication overuse headache has been ruled out by trial and failure of titrating off acute migraine treatments in the past
Member has a documented inadequate response to a 3-month trial of two oral medications from two different classes of drugs for the prevention of migraines (see prophylactic medication list)
Member has a documented inadequate response to (or is unable to tolerate) a minimum trial of at least 12 weeks to two preferred injectable CGRP inhibitors (examples: Aimovig, Ajovy, Emgality) and documentation of clinical response as demonstrated by change in headache frequency, duration and/or severity from baseline must be provided

Documentation Required

Document migraine diagnosis and characteristics

Document the migraine diagnosis and key attack characteristics to support coverage: specify chronic versus frequent episodic phenotype, count and description of attacks (frequency, duration, and characteristics consistent with migraine with or without aura), and steps taken to rule out other causes including medication overuse headache when applicable.

Migraine phenotype: chronic (≥15 headache days/month for >3 months) or frequent episodic (≥5 attacks lasting 4–72 hours)
Attack frequency, duration, and migraine characteristics (e.g., unilateral, pulsating, moderate–severe intensity, nausea/photophobia/phonophobia)
For migraine with aura: aura symptom description and timing criteria when applicable
Documentation that other causes have been ruled out and medication overuse headache has been addressed (trial of titrating off acute treatments if applicable)

Billing Rule

HCPCS unit reporting

Report HCPCS code J3032 using 1 mg = 1 unit. For dosing and unit reporting: a 100 mg dose should be reported as 100 units and a 300 mg dose as 300 units. Dosing is administered every 84 days (every 3 months) as applicable.

J3032 = Injection, eptinezumab-jjmr, 1 mg
100 mg dose = 100 units
300 mg dose = 300 units
Dosing interval: every 84 days (every 3 months)

Billing Rule

Max units per time period

Policy maximum billing limit is 300 billable units per 84 days (i.e., maximum 300 units every 84 days).

Max 300 billable units every 84 days

Denial Risk

Denial risk for concurrent CGRP therapies

Claims may be denied if Vyepti is used concurrently with other prophylactic CGRP antagonists. Examples of CGRP therapies listed in the policy include Aimovig (erenumab), Ajovy (fremanezumab), Emgality (galcanezumab), Nurtec ODT (rimegepant), and Qulipta (atogepant).

Concurrent use with other prophylactic CGRP antagonists may result in claim denial
Examples: Aimovig (erenumab); Ajovy (fremanezumab); Emgality (galcanezumab); Nurtec ODT (rimegepant); Qulipta (atogepant)

Step Therapy

Step therapy failure requirements

Step therapy requirements differ by benefit type. For non‑Medicare members: documented inadequate response to a 3‑month trial of two oral prophylactic medications from two different classes, inadequate response to two preferred injectable CGRP inhibitors (minimum 12 weeks each), and inadequate response to at least two quarterly botulinum toxin injections (6 months). For Medicare members only: failure of one formulary CGRP inhibitor is required instead of two.

Non‑Medicare: Failures required — two oral prophylactics (3 months each, two different classes); two preferred injectable CGRPs (≥12 weeks each); two quarterly botulinum toxin injections (6 months)
Medicare: Failure of one formulary CGRP inhibitor is sufficient