CurrentUnitedHealthcarePolicy CSOH2025D0090.C

Vyepti (Eptinezumab-jjmr) — Medical Benefit Drug Policy (Ohio)

Defines UnitedHealthcare Community Plan medical benefit coverage and medical necessity criteria for Vyepti (eptinezumab-jjmr) in the state of Ohio; applies to requests for this drug under the Ohio plan.

Policy Summary

PayerUnitedHealthcare

PolicyVyepti (Eptinezumab-jjmr) — Medical Benefit Drug Policy (Ohio)

Policy CodePolicy CSOH2025D0090.C

Change TypeRoutine review

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization using the current InterQual guideline for Eptinezumab-jjmr to document medical necessity.

SourceLink

POLICY UPDATE CHANGES

Routine review; no content changes

Ohio-onlystate applicability

J3032listed HCPCS code for drug

InterQualclinical criteria source

Coverage Criteria for Vyepti (eptinezumab-jjmr)

Coverage contingent on InterQual criteria

Covered when InterQual medical necessity criteria for Eptinezumab-jjmr are met.

InterQual-based criteria: All clinical coverage criteria as specified in the current InterQual guideline for Vyepti (Eptinezumab-jjmr) must be met.

Refer to the InterQual CP: Specialty Rx Non-Oncology, Eptinezumab-Jjmr (Vyepti) guideline for the specific requirements.

The presence of a procedure or billing code in this policy is for reference only and does not imply coverage. Benefit coverage and payment are determined by applicable federal, state, or contractual requirements and other plan rules; inclusion of a code is not a guarantee of reimbursement. Refer to other applicable policies and guidelines for coverage determinations and billing guidance.

This policy does not list specific not-medically-necessary conditions within the document. Denial of a request may occur if the patient does not meet the external clinical criteria referenced (InterQual) for Eptinezumab-jjmr (Vyepti) or if coverage is prohibited by federal or state law or other contractual exclusions. Providers should document how the request meets the InterQual medical necessity criteria to avoid potential denials.

Applicable Coding

Policy Summary

PayerUnitedHealthcare

PolicyVyepti (Eptinezumab-jjmr) — Medical Benefit Drug Policy (Ohio)

Policy CodePolicy CSOH2025D0090.C

Change TypeRoutine review

Effective DateNov 1, 2025

Next Review DateN/A

Key ActionSubmit prior authorization using the current InterQual guideline for Eptinezumab-jjmr to document medical necessity.

SourceLink

On This Page

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Provider Actions and Prior Authorization

Prior Authorization

Prior Authorization Required

Prior authorization required. Coverage determinations for Vyepti (eptinezumab‑jjmr) are made using the current InterQual® guideline and UnitedHealthcare prior authorization process. Listing of HCPCS J3032 does not guarantee coverage — benefit coverage is determined by the member's federal, state (OAC), or contractual requirements and applicable law.

Refer to the current InterQual® criteria for specific medical necessity and step‑therapy sequencing requirements.
Prior authorization requests must include documentation that meets InterQual® criteria and any applicable federal, state (OAC), or contractual requirements.
Listing of HCPCS J3032 (Injection, eptinezumab‑jjmr, 1 mg) is for reference; inclusion is not a guarantee of coverage or payment.

Step Therapy

Step Therapy per InterQual®

Step therapy and sequencing per InterQual®. Providers must follow the step‑therapy and sequencing requirements as specified in the InterQual® guideline when requesting coverage for Vyepti. Deviations from InterQual® requirements should be supported by clinical justification and documentation.

Follow InterQual® for initial vs. continuation therapy criteria and any required prior medication trials.
Document rationale when requesting an exception to step‑therapy sequencing.

Documentation Required

Documentation & Evaluation Sources

Documentation and evaluation sources. Evaluation of medical necessity will reference the current InterQual® criteria and applicable federal, state (OAC), or contractual requirements. Ensure submissions include complete clinical records, prior therapy history, and any supporting diagnostic information.

Include clinical notes, prior medication trials, response/tolerability information, and diagnostic evidence with the PA request.
UnitedHealthcare may use third‑party tools (e.g., InterQual®) in benefit administration; in case of conflict, federal/state/contractual requirements govern.

Denial Risk

Coverage Conditional — Verify Benefits

Coverage is conditional. The code listing and policy information are informational only and do not guarantee coverage or payment. Final coverage is determined by the member's benefit plan and by applicable federal, state, or contractual requirements.

Verify member benefits and applicable legal requirements prior to service.
Other policies and guidelines may apply and can affect coverage decisions.

Step	Requirement
1
Step therapy or sequencing requirements (if any) are defined in the current InterQual guideline for Eptinezumab‑jjmr (Vyepti); refer to InterQual CP: Specialty Rx Non‑Oncology, Eptinezumab‑Jjmr for specifics.

Definitions

InterQual criteria definition

DefinitionInterQual guideline: the external clinical criteria referenced for determining medical necessity for Vyepti (eptinezumab-jjmr).

PurposeUsed as the authoritative medical necessity criteria to determine coverage for Vyepti under this policy; providers must refer to the current InterQual CP: Specialty Rx Non-Oncology, Eptinezumab-Jjmr (Vyepti) guideline.

ScopeApplies to clinical coverage determinations and prior authorization decisions for Vyepti (eptinezumab-jjmr) under this UnitedHealthcare Ohio medical benefit drug policy.

AccessRefer to the current release of the InterQual guideline (CP: Specialty Rx Non-Oncology, Eptinezumab-Jjmr) for specific criteria such as diagnosis, prior therapy requirements, and dosing.

Relation to policyThis policy delegates detailed medical necessity criteria to InterQual; coverage is granted only when InterQual criteria are met.

OpenPayer

Vyepti (Eptinezumab-jjmr) — Medical Benefit Drug Policy (Ohio)

Coverage Criteria for Vyepti (eptinezumab-jjmr)

Applicable Coding

Provider Actions and Prior Authorization

Initial Therapy Criteria

Step Therapy / Sequencing

Site of Care Requirements

Definitions

Background