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.

SourceLink

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

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Coverage Summary

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).

Initial Therapy Criteria

Initial Approval Criteria

Coverage is provided when ALL of the following are met:

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

Continuation / Renewal Criteria

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)

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.

Background & Definitions

Vyepti (eptinezumab-jjmr) is a calcitonin gene-related peptide (CGRP) antagonist indicated for the preventive treatment of migraine in adults. The recommended administration is by intravenous infusion at a dose of 100 mg every 3 months, with some patients potentially benefiting from 300 mg every 3 months per clinical criteria. Definitions: MMP = Medicare-Medicaid Plan; CGRP = Calcitonin gene-related peptide.

Revision History

2024-01-04clarified

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

2025-01-08revisedLatest

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