Coverage is subject to the specific terms of the member’s benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the www.fepblue.org website.
The use of eptinezumab (Vyepti) may be considered medically necessary for individuals 18 years of age and older when ALL of the following criteria are met:
- The individual has a diagnosis of ONE (1) 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
- Prescribed by or in consultation with a headache specialist, neurologist, or provider with experience treating migraines; and
- The prescriber attests to ALL of the following:
- Baseline average monthly migraine days; and
- The headaches are not caused by medication rebound or overutilization or due to lifestyle factors; and
- The individual has experienced therapeutic failure or intolerance to one (1) agent from two (2) different prophylactic migraine medication classes or all are contraindicated:
- Alpha-agonists; or
- Angiotensin-converting-enzyme inhibitors or angiotensin II receptor blockers; or
- Anti-epileptic drugs; or
- Beta-blockers; or
- Calcium channel blockers; b
- Onabotulinum toxin A (Botox):
- Note: Acceptable only if the diagnosis is chronic migraines; or
- Serotonin-norepinephrine reuptake inhibitors; or
- Tricyclic antidepressants; and
- Eptinezumab (Vyepti) is not administered concomitantly with any other CGRP therapy; and
- Initial authorization is valid for six (6) months.
Continuation of therapy with eptinezumab (Vyepti) may be considered medically necessary when ALL of the following are met:
- Documentation that the individual has experienced a reduction in ONE (1) of the following:
- Reduction in the number of migraine days per month by at least 50% from baseline; or
- Episodic migraines: a reduction in migraine days per month by at least 4 days from baseline; or
- Chronic migraines: a reduction in migraine days per month by at least 5 days from baseline; and
- Subsequent annual reauthorizations are subject to sustained improvements noted above.
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.