CurrentSecurity Health Plan of Wisconsin, Inc.Policy SHP-0527

Vyepti® (eptinezumab-jjmr) Intravenous Migraine Prevention

Customize your policy alerts

Sign up for security_health_plan_of_wisconsin_inc Policy SHP-0527 alerts

Get alerted when Policy SHP-0527 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

This policy governs prior authorization, dosing, renewal, and coverage criteria for intravenous Vyepti used for preventive treatment of migraine in adults. It applies to Security Health Plan of Wisconsin, Inc. non-Medicare coverage determinations, with separate Medicare rules noted in the policy.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyVyepti® (eptinezumab-jjmr) Intravenous Migraine Prevention

Policy CodePolicy SHP-0527

Change TypeNo material clinical or coverage changes

Effective DateN/A

Last ReviewDec 2, 2025

Next Review DateN/A

Key ActionObtain prior authorization for Vyepti requests and document that all applicable initial or renewal criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+Minimum age for initial approval

6 monthsInitial authorization validity

12 monthsRenewal authorization validity

100 mg/3 moRecommended Vyepti dose

OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

CurrentSecurity Health Plan of Wisconsin, Inc.Policy SHP-0527

Vyepti® (eptinezumab-jjmr) Intravenous Migraine Prevention

Customize your policy alerts

Sign up for security_health_plan_of_wisconsin_inc Policy SHP-0527 alerts

Get alerted when Policy SHP-0527 changes without checking for updates manually.

Monitor payer policy activity

Receive email alerts as soon as relevant payer policies are published or updated.

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyVyepti® (eptinezumab-jjmr) Intravenous Migraine Prevention

Policy CodePolicy SHP-0527

Change TypeNo material clinical or coverage changes

Effective DateN/A

Last ReviewDec 2, 2025

Next Review DateN/A

Key ActionObtain prior authorization for Vyepti requests and document that all applicable initial or renewal criteria are met.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+Minimum age for initial approval

6 monthsInitial authorization validity

12 monthsRenewal authorization validity

100 mg/3 moRecommended Vyepti dose

300/84 daysMaximum billable units

≥50%Standard renewal response

Vyepti Coverage Criteria

Initial approval criteria

Covered for initial approval when ALL of the following are met:

Prior alternative treatment, age, and baseline assessment: The patient must have tried and had an inadequate response, contraindication, or intolerance to an adequate trial of at least one of the following: Aimovig (erenumab), Ajovy (fremanezumab), Emgality (galcanezumab), Qulipta (atogepant), or Nurtec ODT (rimegepant); the patient is at least 18 years of age; and a physician has assessed baseline disease severity using an objective measure or tool such as HIT-6, monthly headache days, MIDAS, or MPFID.Age ≥18 years

Vyepti requests use HCPCS code J3032.

Universal criteria: Other causes of headache have been ruled out; Vyepti is not used in combination with a prophylactic CGRP inhibitor; and the patient is using prophylactic intervention modalities such as trigger avoidance, pharmacotherapy, behavioral therapy, neuromodulation, or physical therapy.

The combination restriction does not apply to CGRP inhibitors used for acute treatment only.

Qualifying migraine indication

Chronic migraine: The patient has 15 or more headache days per month for more than 3 months, and on at least 8 days per month for more than 3 months, the headaches have characteristics and symptoms consistent with migraine.≥15 headache days/month for >3 months; migraine features on ≥8 days/month for >3 months
Frequent episodic migraine: The patient has 4–14 monthly headache days, and on at least 4 days per month, the headaches have characteristics and symptoms consistent with migraine.4–14 headache days/month; migraine features on ≥4 days/month

Renewal criteria

Renewal requires ALL of the following:

Continued eligibility and safety: The patient continues to meet the universal and relevant indication-specific criteria required for initial approval and has no unacceptable toxicity from the drug, such as severe hypersensitivity reactions, uncontrolled hypertension, or development of Raynaud's phenomenon.

Demonstrated treatment response

Headache-day response: There is at least a 50% decrease in monthly migraine days or moderate-to-severe headache days relative to the pretreatment baseline, as supported by diary documentation or medical professional attestation.≥50% decrease
For patients with chronic migraine who have failed prior therapies, a decrease of at least 30% is acceptable.
Validated outcome response: There is a reduction of at least 5 points in MIDAS when the baseline score is 11–20, or at least 30% when the baseline score is greater than 20; or a reduction of at least 5 points in the MPFID score; or a reduction of at least 5 points in the HIT-6 score.

Dosing and escalation

The recommended regimen is 100 mg administered by intravenous infusion every 3 months. Escalation may be considered on a case-by-case basis.

Recommended initial regimen: Administer Vyepti 100 mg by intravenous infusion every 3 months.100 mg IV every 3 months

Patients new to therapy must initiate treatment at 100 mg before increasing to 300 mg, if required.

Dose escalation to 300 mg: Escalation up to 300 mg administered by intravenous infusion every 3 months may occur following clinical review when the patient has had an initial and subsequent loss of response to 100 mg or an inadequate response to 100 mg, such as no net decrease in headache frequency.Up to 300 mg IV every 3 months

Escalation is individualized and requires clinical review.

Use of Vyepti in combination with a prophylactic calcitonin gene-related peptide (CGRP) inhibitor is excluded. This restriction does not apply to a CGRP inhibitor used only for acute treatment.

Codes, Units, and Response Thresholds

HCPCS CodeHCPCSCovered

J3032

Injection, eptinezumab-jjmr, 1 mg: 1 billable unit = 1 mg

NDCNDCCovered

67386-0130-xx

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

Covered Diagnosis CodesICD-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 24

1/3

Covered Diagnosis CodesICD-10Covered

G43.711	Chronic migraine without aura, intractable, with status migrainosus
G43.719	Chronic migraine without aura, intractable, without status migrainosus
G43.E01	Chronic migraine with aura, not intractable, with status migrainosus
G43.E09	Chronic migraine with aura, not intractable, without status migrainosus
G43.E11	Chronic migraine with aura, intractable, with status migrainosus
G43.E19	Chronic migraine with aura, intractable, without status migrainosus

Maximum HCPCS Units

Maximum billable units300 billable units

Billing periodEvery 84 days

Unit typeHCPCS unit

Chronic Migraine Headache Frequency

Monthly headache frequency15 or more headache days per month

DurationMore than 3 months

Migraine-characteristic days

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Prior authorization is required for Vyepti (J3032). Initial authorization is valid for 6 months; renewal authorization may be granted every 12 months when applicable coverage conditions continue to be met.

Initial authorization: 6 months.
Renewal authorization: every 12 months.
Coverage remains subject to the initial or renewal criteria below.

Step Therapy

Trial of One Migraine Preventive Alternative

Before initial approval, document that the patient tried one specified migraine preventive alternative and had an inadequate response, contraindication, or intolerance.

Required alternative: Aimovig (erenumab), Ajovy (fremanezumab), Emgality (galcanezumab), Qulipta (atogepant), or Nurtec ODT (rimegepant).

Therapy Overview

Vyepti (eptinezumab-jjmr) is an intravenous therapy that targets calcitonin gene-related peptide (CGRP) and is used for the preventive treatment of migraine. The policy addresses adults with chronic migraine or frequent episodic migraine who use prophylactic interventions and have documented baseline disease burden. The recommended regimen is 100 mg intravenously every 3 months, with case-by-case escalation to 300 mg for inadequate or lost response.

Clinical Definitions

Chronic Migraine

Headache frequency15 or more headache days per month

DurationMore than 3 months

Migraine characteristics and symptomsPresent on at least 8 days per month for more than 3 months

Frequent Episodic Migraine

Headache frequency4–14 headache days per month

Migraine characteristics and symptomsPresent on at least 4 days per month

DefinitionFrequent episodic migraine

Policy Summary

PayerSecurity Health Plan of Wisconsin, Inc.

PolicyVyepti® (eptinezumab-jjmr) Intravenous Migraine Prevention

Policy CodePolicy SHP-0527

Change TypeNo material clinical or coverage changes

Effective DateN/A

Last ReviewDec 2, 2025

Next Review DateN/A

Key ActionObtain prior authorization for Vyepti requests and document that all applicable initial or renewal criteria are met.

SourceLink

On This Page

MIDAS: ≥5 points or ≥30%; MPFID: ≥5 points; HIT-6: ≥5 points

At least 8 days per month for more than 3 months

Frequent Episodic Migraine Headache Frequency

Monthly headache frequency4–14 headache days per month

Migraine-characteristic daysAt least 4 days per month

ConditionHeadaches have characteristics and symptoms consistent with migraine

Standard Renewal Response

Required reductionAt least 50%

Applicable measuresMonthly migraine days or moderate-to-severe headache days

Comparison pointRelative to the pretreatment baseline

Chronic Migraine Renewal Response After Prior Therapy Failure

Required reductionAt least 30%

Applicable measuresMonthly migraine days or moderate-to-severe headache days

ApplicabilityPatients with chronic migraine who have failed prior therapies

MIDAS Improvement

Baseline score 11–20Reduction of at least 5 points

Baseline score above 20Reduction of at least 30%

Outcome measureMIDAS score

MPFID Improvement

Required reductionAt least 5 points

Outcome measureMPFID score

UseClinically meaningful improvement for renewal

HIT-6 Improvement

Required reductionAt least 5 points

Outcome measureHIT-6 score

UseClinically meaningful improvement for renewal

Documentation Required

Initial Clinical Documentation

Submit initial clinical documentation supporting the diagnosis, disease burden, migraine features, exclusion of alternative causes, and use of preventive interventions. Baseline severity must be assessed with an objective measure or validated tool.

Patient is at least 18 years of age.
Document chronic migraine: at least 15 headache days per month for more than 3 months, with migraine characteristics on at least 8 days per month; or frequent episodic migraine: 4–14 headache days per month, with migraine characteristics on at least 4 days per month.
Record migraine-consistent headache characteristics and symptoms.
Document baseline severity using an objective measure/tool, such as HIT-6, monthly headache days, MIDAS, or MPFID.
Document that other causes of headache have been ruled out.
Document use of prophylactic intervention modalities, such as trigger avoidance, pharmacotherapy, behavioral therapy, neuromodulation, or physical therapy.

Documentation Required

Prior Alternative Treatment History

Document the patient’s prior migraine preventive treatment history and the adequate trial of the specified alternatives before requesting initial Vyepti approval.

Document the alternative drug tried: Aimovig, Ajovy, Emgality, Qulipta, or Nurtec ODT.
Record the duration and adequacy of the trial and the resulting inadequate response, contraindication, or intolerance.

Documentation Required

Renewal Response and Safety Evidence

For renewal, document continued eligibility, absence of unacceptable toxicity, and clinically meaningful response from the pretreatment baseline. Response may be established by diary documentation or professional attestation and must include a validated outcome when applicable.

Document at least a 50% decrease in monthly migraine days or moderate-to-severe headache days from baseline by diary or medical professional attestation.
For chronic migraine patients who failed prior therapies, a decrease of at least 30% is acceptable.
Alternatively, document validated improvement: MIDAS reduction of at least 5 points when baseline score is 11–20 or at least 30% when baseline score is greater than 20; MPFID reduction of at least 5 points; or HIT-6 reduction of at least 5 points.
Document no unacceptable toxicity, including severe hypersensitivity reactions, uncontrolled hypertension, or development of Raynaud’s phenomenon.

Documentation Required

Dose Escalation Documentation

Dose escalation above the initial 100 mg regimen requires case-by-case clinical review. Document the patient’s response history on 100 mg and the rationale for increasing to 300 mg.

New patients must start at 100 mg intravenously every 3 months before increasing, if needed.
For escalation, document either an initial and subsequent loss of response to 100 mg or an inadequate response, such as no net decrease in headache frequency.
Support the request for 300 mg with the clinical rationale and response history; 300 mg is administered intravenously every 3 months and is subject to the maximum dose and frequency.

Note

Medicare Coverage Requirements

Medicare determinations must comply with the Medicare Benefit Policy Manual requirements for outpatient Part B drugs and any applicable NCDs, LCDs, or LCAs.

Apply Medicare Benefit Policy Manual (Pub. 100-2), Chapter 15, §50, Drugs and Biologicals.
Review applicable CMS NCDs, LCDs, and LCAs for coverage and claims-payment requirements.

Denial Risk

Initial Criteria Not Met

Initial approval should be denied when required clinical eligibility or prior-treatment criteria are not documented or are not met.

Patient is younger than 18 years of age.
Chronic or frequent episodic migraine criteria are not met.
Required migraine features, headache frequency, or duration are not documented.
The patient has not tried a specified preventive alternative or did not demonstrate an inadequate response, contraindication, or intolerance.
The patient cannot use or has not completed an adequate trial of a required alternative without an accepted clinical reason.

Denial Risk

Universal Criteria Failure

Coverage should be denied or held when universal requirements are not satisfied, including exclusion of other headache causes, appropriate prophylactic intervention, or avoidance of prohibited combination therapy.

Other causes of headache have not been ruled out.
Vyepti is being used with a prophylactic CGRP inhibitor; this does not apply to a CGRP inhibitor used only for acute treatment.
The patient is not utilizing appropriate prophylactic intervention modalities.

Denial Risk

Renewal Response or Safety Failure

Renewal should be denied when the patient has unacceptable toxicity or the record does not demonstrate the required response or meaningful validated improvement from baseline.

Unacceptable toxicity is present, such as severe hypersensitivity reactions, uncontrolled hypertension, or development of Raynaud’s phenomenon.
The required reduction in migraine or moderate-to-severe headache days is not demonstrated.
No clinically meaningful improvement is documented on an accepted validated measure.
Required diary documentation, medical professional attestation, or outcome-measure evidence is missing.

Billing Rule

Dose or Billing Limit Exceeded

Do not exceed 300 billable units every 84 days. Claims for J3032 must use the code’s definition of 1 billable unit equal to 1 mg of eptinezumab-jjmr.

Maximum: 300 units per dose and over time every 84 days.
HCPCS J3032: Injection, eptinezumab-jjmr, 1 mg.
Billing quantities inconsistent with the 1 mg-per-unit definition or exceeding the 300-unit limit may trigger denial or review.

Disease Response

Standard responseAt least 50% decrease in monthly migraine days or moderate-to-severe headache days

BaselineReduction is measured relative to the pretreatment baseline

Chronic migraine exceptionAt least 30% decrease is acceptable for chronic migraine patients who have failed prior therapies