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S.5.01.529
Vyepti (eptinezumab-jjmr)
Please perform a search of the State Health Plan Medical Drug Formulary for drugs administered and billed through the medical setting.
Migraine is a headache disorder characterized by recurrent moderate to severe headaches with associated symptoms. For patients who experience more than four migraine days per month, preventive treatment may be recommended. Evidence implicates calcitonin gene-related peptide (CGRP) in migraines, and monoclonal antibodies (mAbs) for the CGRP receptor and molecule have been developed for migraine prophylaxis.
Migraine
Approximately 15% of the population have migraines, with a higher prevalence in women than in men. The typical migraine headache is throbbing, unilateral, and aggravated by motion. Migraines are frequently associated with nausea, vomiting, photophobia, and phonophobia, although other neurological symptoms may occur. Migraine attacks can last from several hours to several days and are often preceded by transient neurological symptoms (e.g. visual disturbance) known as migraine aura.Migraines are categorized as episodic or chronic depending on the frequency of attacks. Episodic migraine is defined as migraine or headache for less than 15 days per month and accounts for more than 90% of cases of migraine. Chronic migraine is defined as 15 or more headache days each month, of which at least 8 are migraine days.Migraine was previously thought to be primarily vascular, but recent evidence suggests that sensitization of pain pathways in the central nervous system may be involved. At least three messenger molecules are thought to be involved during migraine attacks: nitric oxide, 5-hydroxytryptamine (5-HT) and CGRP. CGRP is produced in both peripheral and central neurons and is a potent vasodilator. Some preclinical studies suggest that during a migraine, sensory neurons in the trigeminal ganglion release CGRP from their peripherally projecting nerve endings in the meninges.
Treatment
Symptomatic treatment is available for migraine attacks. Other medications such as triptans (5-HT agonists) taken at the onset of a migraine may reduce the severity and duration of the attack. For patients who experience more than 4 migraine days per month, preventive treatment may be recommended. Most of the pharmaceutical agents that reduce migraine attack frequency and severity are antidepressants, anticonvulsants or antihypertensives, and were not developed specifically to prevent migraine. Oral medications approved by the U.S. Food and Drug Administration (FDA) for migraine prophylaxis include topiramate, propranolol, timolol, and valproate. All of these medications have contraindications and side effects that limit their use. Botulinum toxin injections in the head or neck may also be used.
This policy addresses humanized monoclonal antibodies (mAbs) that bind to the CGRP receptor or CGRP molecule and are designed specifically for the prevention of migraine. Unlike oral drug therapy, monoclonal antibodies are not metabolized by the liver can remain in the body for weeks or months. Vyepti (eptinezumab-jjmr) is indicated for the preventive treatment of migraine in adults.
Related medical policies -
Vyepti (eptinezumab-jjmr) is considered not medically necessary as there are other formulary alternatives covered by the Plan for the preventive treatment of migraines.
Services related to delivery and/or administration of a medication determined to be not medically necessary will also be considered not medically necessary.
None
Medical Policy Manual coverage guidelines should not be used in lieu of the Participant's specific benefit plan language outlined in the Mississippi's State and School Employees’ Life and Health Insurance Plan.
Medication failure is defined as disease progression despite maximally tolerated dose (≥3 months use) as appropriate for disease state being treated. Experience of common side effects of medication will not be considered medication failure for the purpose of this review.
Medically Necessary is defined as those services, treatments, procedures, equipment, drugs, devices, items or supplies furnished by a covered Provider that are required to identify or treat a Participant's illness, injury or Mental Health Disorders, and which Company determines are covered under this Benefit Plan based on the criteria as follows in A through D:
A. consistent with the symptoms or diagnosis and treatment of the Participant's condition, illness, or injury; and
B. appropriate with regard to standards of good medical practice; and
C. not solely for the convenience of the Participant, his or her Provider; and
D. the most appropriate supply or level of care which can safely be provided to the Participant. When applied to the care of an Inpatient, it further means that services for the Participant's medical symptoms or conditions require that the services cannot be safely provided to the Participant as an Outpatient.
For the definition of medical necessity, “standards of good medical practice” means standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, and physician specialty society recommendations, and the views of medical practitioners practicing in relevant clinical areas and any other relevant factors. BCBSMS makes no payment for services, treatments, procedures, equipment, drugs, devices, items or supplies which are not documented to be Medically Necessary. The fact that a Physician or other Provider has prescribed, ordered, recommended, or approved a service or supply does not in itself, make it Medically Necessary.
07/01/2023: New policy added.
06/03/2025: Policy reviewed and approved by the Pharmacy & Therapeutics (P&T) Committee. Policy description updated regarding indications for Vyepti (eptinezumab-jjmr). Policy statements unchanged. Sources updated.
Blue Cross Blue Shield Association policy # 5.01.29
Vyepti prescribing information. Lundbeck Pharmaceuticals LLC. March 2025. Last accessed April 2025.
This may not be a comprehensive list of procedure codes applicable to this policy.
Not Medically Necessary Codes
Code Number | Description |
CPT-4 | |
HCPCS | |
J3032 | Injection, eptinezumab-jjmr, 1 mg |
ICD-10 Procedure | |
ICD-10 Diagnosis |
CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.