For Migraine Prevention
(Vyepti)
If
approved, initial authorization will be for six (6) months.
Vyepti (eptinezumab) is
considered medically necessary in members meeting the following conditions:
1)
Patient is 18 years of
age or older; AND
2)
Diagnosis of migraine
headaches; AND
3)
Being used for the
prevention of migraines; AND
4)
Documentation of at least
eight (8) migraines per month; AND
5)
Patient has had
inadequate response to an adequate trial (60 days) of a product from at least
two of the drug classes below:
a.
Beta Blockers (e.g.
atenolol, propranolol)
b.
Anticonvulsants (e.g.
topiramate, gabapentin, divalproex)
c.
Antidepressants (e.g.
amitriptyline, venlafaxine)
d.
Calcium Channel Blockers
(e.g. verapamil); AND
6)
Member will not be using
Vyepti with Botox for prevention of migraines.
7)
Members will be using
only one CGRP inhibitor for prevention of migraines.
Re-authorization criteria
(12 months duration):
1)
Documented decrease of
> 50% in migraine frequency from baseline; AND
2)
Decrease in use of acute
migraine medications; AND
3)
No dual therapy with
Botox.