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 criteria as outlined in prescribing information (PI) including recommendations for diagnosis and age; and
- The prescriber is, or is in consult with a neurologist, or specialist in migraine treatment and prevention; and
- The individual has a diagnosis of ONE of the following:
- Episodic migraine defined as 4 to 14 headache days per month; or
- Chronic migraine defined as 15 or more headache days per month of which 8 or more are migraine days; and
- The individual must have had 2-month trials of at least two 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
- The prescriber must submit documentation, including clinical notes regarding:
- Failure of prior treatments to reduce migraine frequency after 2-month trial; and
- Baseline average monthly migraine days; and
- The individual has had a 90-day trial with each self-administered CGRP (Ajovy, Emgality, and Aimovig).
Initial Authorization: 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).
Continuation Authorization: 12 months
The use of eptinezumab (Vyepti) for any other indication than listed above is considered experimental/investigational and therefore, not covered. The safety and/or efficacy cannot be established by review of the available published peer-reviewed literature.