CommercialPrior AuthHigh impact
Eptinezumab-jjmr (Vyepti) (CPB 0970, reviewed 2025-12-09)
Aetna·Neurology, Pain Management, Internal Medicine·Medical Policy
Effective date
Dec 9, 2025
We identified it
Aug 13, 2026
Summary
Aetna has updated its clinical policy for eptinezumab-jjmr (Vyepti), a CGRP monoclonal antibody for migraine prevention. The policy requires precertification for all uses, mandates a minimum of 3 months of treatment before initial approval, and requires documented reduction in migraine days per month for continuation therapy. Billing teams must implement prior authorization workflows and ensure proper coding with HCPCS code J3032 paired with IV infusion CPT codes.
Action Required
Immediately: 1) Billing team must configure system to require Aetna precertification for all Vyepti (eptinezumab-jjmr) claims for commercial plans before claim submission. Call (866) 752-7021 or fax (888) 267-3277 for precertification; obtain Statement of Medical Necessity (SMN) forms from Specialty Pharmacy Precertification. 2) Update billing software to enforce initial approval criteria: member has NOT received 3 months of prior Vyepti treatment. 3) For continuation requests, require documentation of baseline migraine days and reduction in migraine days per month from baseline to approve. 4) Link HCPCS code J3032 (1 mg eptinezumab-jjmr) with CPT codes 96365 (initial IV infusion, up to 1 hour) and 96366 (each additional hour). 5) Ensure clinical staff document standard dosing (100 mg or 300 mg IV every 3 months) in medical record for billing support. 6) Review Site of Care Utilization Management Policy for specialty drug infusion location requirements. Failure to obtain precertification will result in claim denials.