CurrentUnitedHealthcarePolicy CS2025D0090P

Vyepti (Eptinezumab-Jjmr) Medical Benefit Drug Policy

Defines UnitedHealthcare Medical Benefit Drug Policy coverage criteria, continuation criteria, exclusions, applicable HCPCS and ICD-10 codes, state-specific application exceptions, dosing/frequency constraints, and authorization durations for Vyepti (eptinezumab-jjmr) for preventive treatment of migraine in adults.

Policy Summary

PayerUnitedHealthcare

PolicyVyepti (Eptinezumab-Jjmr) Medical Benefit Drug Policy

Policy CodePolicy CS2025D0090P

Change TypeApplication revision — state exclusions

Effective DateNov 1, 2025

Next Review Date

Key ActionProviders must obtain authorization and document diagnosis, migraine frequency, prior trials/failures or contraindications/intolerances to required therapies, and attest Vyepti will not be used with other biologic CGRP antagonists; authorizations issued for up to 12 months.

POLICY UPDATE CHANGES

Application: Added language indicating the Medical Benefit Drug Policy does not apply to Arizona and Washington; refer to the state's Medicaid clinical policy.

12Max authorization duration

J3032HCPCS code

>=2Required prior traditional prophylactics failed

>=2Required prior CGRP biologic/oral CGRP therapies failed

Coverage Summary

Vyepti (eptinezumab-jjmr) is covered under this UnitedHealthcare Medical Benefit Drug Policy (Policy Number CS2025D0090P) for the preventive treatment of migraine in adults when the policy criteria are met. The policy is effective November 1, 2025 and defines diagnostic, prior therapy, dosing, and authorization requirements for initial and continued use. This Medical Benefit Drug Policy does not apply to the states of Arizona and Washington; refer to the respective state Medicaid clinical policy as noted in the policy history.

Applicable Codes

Covered HCPCS (drug supply billing)HCPCSCovered

J3032

Injection, eptinezumab-jjmr, 1 mg

Relevant Diagnosis Codes (for reference)ICD-10

G43.001	Migraine without aura, not intractable, with status migrainosus
G43.009	Migraine without aura, not intractable, without 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
G43.411	Hemiplegic migraine, intractable, with status migrainosus

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1/5

Provider Actions & Authorization Requirements

Prior Authorization

Authorization required with criteria documentation

Providers must obtain authorization for Vyepti and document diagnosis per the International Classification of Headache Disorders, 3rd edition, migraine frequency per the policy thresholds, prior trials and failures/contraindications/intolerances to required therapies with specified trial durations, and attest that Vyepti will not be used concomitantly with another biologic CGRP antagonist; authorizations will be issued for up to 12 months.

Affected code: J3032

Documentation Required

Document prior prophylactic therapy trials

Document trial and failure (or contraindication/intolerance) to two traditional prophylactic therapies after trials of at least two months each, and trial and failure (or contraindication/intolerance) to two preventive CGRP biologic or oral CGRP therapies after trials of at least three months each, as applicable, before initial approval.

Documentation Required

Demonstrate positive response for continuation

For reauthorization, document that the patient has experienced a positive response to therapy, demonstrated by a reduction in headache frequency and/or intensity per the policy definition for continuation; reauthorizations are issued for no more than 12 months.

Clinical Evidence

4.3PROMISE 1 (300 mg): reduction in monthly migraine days vs placebo

3.9PROMISE 1 (100 mg): reduction in monthly migraine days vs placebo

8.2PROMISE 2 (eptinezumab): reduction in monthly migraine days (vs 5.6 placebo)

61%>=50% response rate in PROMISE 2 (eptinezumab) vs 39% placebo

Phase 3 trials PROMISE 1 (episodic migraine) and PROMISE 2 (chronic migraine) demonstrated that eptinezumab significantly reduced monthly migraine days versus placebo and had an overall safety profile similar to placebo, supporting efficacy and acceptable tolerability for preventive treatment of migraine in adults.

Background & Definitions

Vyepti is a humanized IgG1 monoclonal antibody that specifically binds the CGRP ligand and blocks its receptor binding. It is FDA-indicated for the preventive treatment of migraine in adults. The recommended administration is by intravenous infusion every 3 months, with a usual dose of 100 mg and some patients benefiting from 300 mg.

Term	Definition
Positive response to therapy	Demonstrated reduction in headache frequency and/or intensity (per policy requirement for continuation)
Predominant headache diagnosis	Provider attestation that the primary driver of headaches is migraine rather than a different, non-migrainous condition

Policy Summary

PayerUnitedHealthcare

PolicyVyepti (Eptinezumab-Jjmr) Medical Benefit Drug Policy

Policy CodePolicy CS2025D0090P

Change TypeApplication revision — state exclusions

Effective DateNov 1, 2025

Next Review Date

On This Page

OpenPayer

Vyepti (Eptinezumab-Jjmr) Medical Benefit Drug Policy

Coverage Summary

Initial Therapy — Preventive Treatment (Adults)

Continuation / Reauthorization Criteria

Not Medically Necessary / Unproven Indications

Applicable Codes

Provider Actions & Authorization Requirements

Clinical Evidence

Background & Definitions

Revision History