Anthem Blue Cross (HMO, PPO, EPO)
Vyepti (eptinezumab-jjmr)
Drugs for the Nervous System : Drugs for Migraine Headaches

  • For FAX form click HERE
    Our electronic prior authorization (ePA) process is the preferred method for submitting pharmacy prior authorization requests. Creating an account is free, easy and helps patients get their medications sooner. You can complete the process through your current electronic health record/electronic medical record (EHR/EMR) system or by using one of these ePA sites:
     Log in to Surescripts
     Log in to CoverMyMeds; For details on drug coverage click HERE;
  • Migraine:
    Duration: 6 Month(s)
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 year(s)
    Migraine Frequency: 4 per month
    Is supporting documentation required for initial approval: No
    Is supporting documentation required for re-approval: No
    Policy Contains Verbiage for Botulinum Interchangeability: No
    Diagnosis of Chronic Migraine Required: Yes
    Required Decrease in Duration of Chronic Migraine for Reauthorization: Unspecified
    Provider Responsibility Language Referenced in Policy: No
    Dose Conversion Language Included in Policy: No
    Reauthorization Criteria Includes 50% Reduction Language: No
    Reauthorization Criteria Includes 7 Day100 Hour Reduction Language: No
    Retreatment Language Included in Policy: N/A
    Policy Contains ICHD2 or ICHD3 Language: No ICHD2 or ICHD3 criteria exist

    Migraine Prevention:
    Duration: 3 Month(s)
    Documented Diagnosis: Yes

  • Quantity Limit: 1 vial per 3 months(s).
  • Prior Authorization: Migraine:
    Documented Diagnosis: Yes
    Duration: 6 Month(s)
    Reauthorization Required: Yes

    Migraine Prevention:
    Documented Diagnosis: Yes
    Duration: 3 Month(s)

  • PA Applies
  • Step Therapy: ST Generic and Brand