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
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.