Criteria
Coverage is subject to the specific terms of the member’s benefit plan.
The use of eptinezumab (Vyepti) may be considered medically necessary when ALL of the following criteria are met:
- The individual must meet FDA-approved label for use (e.g., use outside of studied population will be considered investigational); and
- The requested medication must be prescribed by, or in consult with, a neurologist, or specialist in migraine treatment and prevention; and
- The individual must experience three (3) or more migraine days per month; and
- The individual must have failed two (2)-month trials of at least two (2) of the following agents from different therapeutic classes, as evidenced by paid claims or pharmacy printouts:
- amitriptyline, atenolol, divalproex sodium, metoprolol, nadolol, propranolol, timolol, topiramate, venlafaxine; and
- Documentation must include clinical notes regarding failure of prior treatments to reduce migraine frequency after each two (2)-month trial; and
- The individual must have failed a three (3)-month trial of each self-administered CGRP (Ajovy, Emgality, and Aimovig), as evidenced by paid claims or pharmacy printouts.
Initial Authorization: Six (6) months
Reauthorization Criteria
Continuation of therapy with eptinezumab (Vyepti) may be considered medically necessary when the following is met:
- The individual must have experienced at least a 50% reduction in migraine days from baseline, since starting treatment with eptinezumab (Vyepti).
The use of eptinezumab (Vyepti) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Codes
