Eptinezumab-jjmr (Vyepti) (Medicaid Expansion)

Policy ID: ME-I-222-004-05

Section: Injections

Effective Date: January 01, 2022

Revised Date: March 05, 2025

Revision Effective Date: April 01, 2025

Last Reviewed: March 11, 2025

Applies To: Medicaid Expansion Only

Description

Eptinezumab-jjmr (Vyepti™) is a humanized monoclonal antibody that binds to calcitonin gene-related peptide (CGRP) ligand and blocks its binding to the receptor. Administered intravenously, eptinezumab-jjmr (Vyepti) is a preventive treatment of migraines.

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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 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, candesartan, divalproex sodium, metoprolol, nadolol, propranolol, topiramate, venlafaxine, zonisamide; and
The individual must have failed a 3-month trial of Ajovy, Emgality, Aimovig, Qulipta and Nurtec ODT , as evidenced by paid claims or pharmacy printouts.

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 Code

J3032

NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the United States Food and Drug Administration (U.S. FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines.

Diagnosis Codes

G43.001

G43.009

G43.011

G43.019

G43.101

G43.109

G43.111

G43.119

G43.401

G43.409

G43.411

G43.419

G43.501

G43.509

G43.511

G43.519

G43.701

G43.709

G43.711

G43.719

G43.801

G43.809

G43.811

G43.819

G43.901

G43.909

G43.911

G43.919

G43.E01

G43.E09

G43.E11

G43.E19

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-23-2021 - Effective January 1, 2022

Adopted Medicaid Expansion specific policy

Internal Medical Policy Committee 11-29-2022 - Effective January 1, 2023

Updated initial criteria, and
Updated experimental/investigational statement

Internal Medical Policy Committee 9-12-2023 Effective September 01, 2023

Updated initial criteria based on the DHHS PDL Version 2023.4

Internal Medical Policy Committee 9-17-2024 Effective October 01, 2024

Updated initial criteria based on the DHHS PDL Version 2024.5

Internal Medical Policy Committee 03-11-2025 Effective April 01, 2025

Updated initial criteria required based on the DHHS PDL Version 2025.2
Updated diagnosis codes

Links

References (PDF)

Disclaimer

Current medical policy is to be used in determining a Member's contract benefits on the date that services are rendered. Contract language, including definitions and specific inclusions/exclusions, as well as state and federal law, must be considered in determining eligibility for coverage. Members must consult their applicable benefit plans or contact a Member Services representative for specific coverage information. Likewise, medical policy, which addresses the issue(s) in any specific case, should be considered before utilizing medical opinion in adjudication. Medical technology is constantly evolving, and the Company reserves the right to review and update medical policy periodically.

Policy ID: ME-I-222-004-04

Section: Injections

Effective Date: January 01, 2022

Revised Date: September 11, 2024

Revision Effective Date: October 01, 2024

Last Reviewed: September 17, 2024

Archived Date: March 31, 2025

Applies To: Medicaid Expansion Only

Description

Policy Application

All claims submitted for this policy will be processed according to the policy effective date and associated revision effective dates in effect on the date of service.

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 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, candesartan, divalproex sodium, metoprolol, nadolol, propranolol, topiramate, venlafaxine, zonisamide; and
The individual must have failed a three (3)-month trial of both of the following self-administered CGRP
- Ajovy and Emgality , as evidenced by paid claims or pharmacy printouts; and
The individual must have failed a three (3)-month trial of Qulipta , as evidenced by paid claims or pharmacy printouts.

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).

Procedure Code

J3032

Diagnosis Codes

G43.001

G43.009

G43.011

G43.019

G43.101

G43.109

G43.111

G43.119

C43.401

C43.409

G43.411

G43.419

G43.501

G43.509

G43.511

G43.519

G43.701

G43.709

G43.711

G43.719

G43.801

G43.809

G43.811

G43.819

G43.901

G43.909

G43.911

G43.919

Professional Statements and Societal Positions Guidelines

Not Applicable

ND Committee Review

Internal Medical Policy Committee 11-23-2021 - Effective January 1, 2022

Adopted Medicaid Expansion specific policy

Internal Medical Policy Committee 11-29-2022 - Effective January 1, 2023

Updated initial criteria, and
Updated experimental/investigational statement

Internal Medical Policy Committee 9-12-2023 Effective September 01, 2023

Updated initial criteria based on the DHHS PDL Version 2023.4

Internal Medical Policy Committee 9-17-2024 Effective October 01, 2024

Updated initial criteria based on the DHHS PDL Version 2024.5

Medical Policies Quick Search

Eptinezumab-jjmr (Vyepti) (Medicaid Expansion)

Description

Policy Application

Criteria

Procedure Code

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer

Description

Policy Application

Criteria

Procedure Code

Diagnosis Codes

Professional Statements and Societal Positions Guidelines

ND Committee Review

Links

Disclaimer