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 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
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).
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.
Procedure Codes
