Coverage Policies

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INDEX:
A B C D E F G H I J K L M N O P Q R S T U V W X Y Z

Effective Date: 11/01/2018 Title: Vyepti - Calcitonin Gene Related Peptide (CGRP) Inhibitors
Revision Date: 01/01/2022 Document: BI585:00
CPT Code(s): J3032
Public Statement

Effective Date:

a)    This policy will apply to all services performed on or after the above revision date which will become the new effective date.

b)    For all services referred to in this policy that were performed before the revision date, contact customer service for the rules that would apply.

1)    Vyepti (eptinozumab) requires prior authorization.

2)    Vyepti (eptinezumab) is used for the prevention of migraine headaches.

3)    Vyepti is covered under the medical benefit.


Medical Statement

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.


Limits

Vyepti is limited to one (1) 300mg dose every 3 months.


Reference

1)    Aimovig Prescribing Information.  Amgen. May 2018.

2)    Emgality Prescribing Information. Eli Lilly. September 2018.

3)    Ubrelvy Prescribing Information. Madison, NJ; Allergan USA, Inc. December 2019.

4)    Nurtec Prescribing Information. New Haven, CT; Biohaven Pharmaceuticals, Inc. February 2020.

5)    Clinical Pharmacology. Accessed online 04-30-20.

Addendum:

1)    Effective 04-01-2019: Updated title to Calcitonin Gene Related Peptide (CGRP) Inhibitors and added coverage criteria for Emgality along with Aimovig. Noted Ajovy is not covered. Removed requirement for triptan use.

2)    Effective 11-01-2019:  Updated with max limits per FDA prescribing guidelines.

3)    Effective 04/01/2020: Updated with specific criteria for coverage of Emgality for episodic cluster headaches.

4)    Effective 06/01/2020: Updated to include coverage criteria for oral CGRP inhibitors (Ubrelvy and Nurtec) and IV Vyepti.

5)    Effective 1/1/2022: Updated to remove products covered under the pharmacy benefit. Refer to MagellanRx formulary for coverage of those products.


Application to Products
This policy applies to all health plans administered by QualChoice, both those insured by QualChoice and those that are self-funded by the sponsoring employer, unless there is indication in this policy otherwise or a stated exclusion in your medical plan booklet. Consult the individual plan sponsor Summary Plan Description (SPD) for self-insured plans or the specific Evidence of Coverage (EOC) for those plans insured by QualChoice. In the event of a discrepancy between this policy and a self-insured customer’s SPD or the specific QualChoice EOC, the SPD or EOC, as applicable, will prevail. State and federal mandates will be followed as they apply.
Changes: QualChoice reserves the right to alter, amend, change or supplement benefit interpretations as needed.
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