Anthem: Vyepti Payer Policy (Beta Access)

Other Pertinent Information:

• Vyepti is a calcitonin gene-related peptide (CGRP) inhibitor.
  • Should not be used concurrently with another CGRP inhibitor (Aimovig, Ajovy, Emgality, Qulipta, Nurtec ODT).
  • Can be used concurrently with botulinum toxin for migraine prophylaxis under specific conditions (see criteria below).

Quantity Limits:

• Standard dose: 1 vial (100 mg) per 3 months.
  • Override Criteria: Members with an inadequate response to 100 mg may be approved for 3 vials (300 mg) every 3 months.

Exclusion(s):

• Combination therapy with another CGRP inhibitor for migraine prophylaxis (Aimovig, Ajovy, Emgality, Qulipta, or Nurtec ODT).
• Use for acute migraine treatment (Vyepti is only approved for prevention).

Initial Approval Criteria:

Vyepti is medically necessary for patients who meet all the following criteria:

1. Diagnosis of migraine requiring preventive treatment, with one of the following:
   • Episodic migraine: 4 to 14 migraine days per month, with fewer than 15 headache days per month (previous 3-month average).
   • Chronic migraine: 15 or more headache days per month, with at least 8 migraine days per month for more than 3 months.
2. Vyepti is being used for migraine prophylaxis.
3. If the member is using botulinum toxin concurrently with Vyepti, the following must apply:
   • The member has experienced a reduction in migraine days or severity with botulinum toxin.
   • The member continues to experience a significant number of migraine days, requiring additional therapy for prevention.
4. Dosing aligns with FDA-approved guidelines.
5. Initial authorization period: 6 months (two injection cycles).

Continuation Criteria:

For continued coverage, all the following must be met:

1. Patient has previously received Vyepti.
2. Documented positive clinical response, defined as:
   • A reduction in overall migraine days or a reduction in the severity of migraine days per month.
   • A clinical benefit deemed significant by the prescriber, such as:
     • 50% reduction in headache/migraine frequency.
     • Significant decrease in migraine duration.
     • Significant decrease in migraine severity.
     • Improved response to acute migraine treatment.
     • Reduction in migraine-related disability and improved functioning.
     • Improvement in quality of life and reduction in migraine-related stress.
3. If the member is using botulinum toxin concurrently with Vyepti, the following must apply:
   • The member has had further reduction in migraine days compared to botulinum toxin alone.
4. Reauthorization period: 12 months.

Sources:

1. Vyepti [prescribing information]. Lundbeck; 2022.
2. American Headache Society (2021). CGRP-Targeting Therapies Consensus Statement.
3. Anthem Commercial Medical Benefit Drug Policy – Effective 2024.

Additonal Resources

1. Medical Specialty Precertification Drug List: https://file.anthem.com/06347MUPENABS.pdf
2. Medical Step Therapy Drug List: https://file.anthem.com/A02605ANPENABS.pdf
3. Site of Care Drug List: https://file.anthem.com/06346MUPENABS.pdf