Page reviewed Aug 23, 2026 · from FDA-approved labeling (Drugs@FDA) — no drug-specific Medicare LCD
Quick answer
Medicare benefit
Part B (physician-administered)
FDA-indicated diagnoses
13 ICD-10 codes
Governing policy
FDA indications (no LCD)
Contractor (MAC)
Per medical necessity
Source
FDA labeling
Page reviewed
Aug 23, 2026
HCPCS codes covered:
J3032
J3032
No drug-specific Medicare coverage article exists for Vyepti. Coverage is decided per medical necessity by your MAC. The FDA-approved indications below are the labeled uses Medicare generally pays for; an off-label use may be covered if supported by an approved compendium. Find your MAC by state →
What Medicare pays for Vyepti (2026 Q3)
Once a claim carries a covered diagnosis, Medicare Part B reimburses the drug at the ASP + 6% payment limit. Current allowed amounts per billing unit:
| HCPCS | Description | Per unit | Allowed (ASP + 6%) |
|---|---|---|---|
| J3032 | Inj. eptinezumab-jjmr 1 mg | 1 mg | $21.101 |
Source: CMS ASP Drug Pricing File, 2026 Q3. Payment = ASP + 6% per unit; multiply by units billed (watch JZ/JW wastage). Your patient's share is typically 20% after the deductible. Estimate the full cost & patient out-of-pocket →
Vyepti is a physician-administered biologic billed under Medicare Part B (not the Part D pharmacy benefit). Under Part B, Medicare pays the practice for the drug (HCPCS J3032) plus its administration — but only when the claim's diagnosis (ICD-10) code supports medical necessity. Each MAC publishes the specific covered diagnoses in a Billing & Coding Article; a claim with a diagnosis outside that list is typically denied as not medically necessary (CO-50).
Covered ICD-10 diagnoses for Vyepti
The 13 FDA-approved indications for J3032, grouped by condition — filter to find a code.
Episodic Migraine — 3 diagnoses (applies to J3032)
Diseases of the nervous system (3)
| ICD-10 | Covered diagnosis |
|---|---|
| G43.009 | Migraine without aura, not intractable, without status migrainosus |
| G43.109 | Migraine with aura, not intractable, without status migrainosus |
| G43.909 | Migraine, unspecified, not intractable, without status migrainosus |
Chronic Migraine — 5 diagnoses (applies to J3032)
Diseases of the nervous system (5)
| ICD-10 | Covered diagnosis |
|---|---|
| G43.701 | Chronic migraine without aura, not intractable, with status migrainosus |
| G43.709 | Chronic migraine without aura, not intractable, without status migrainosus |
| G43.711 | Chronic migraine without aura, intractable, with status migrainosus |
| G43.719 | Chronic migraine without aura, intractable, without status migrainosus |
| G43.919 | Migraine, unspecified, intractable, without status migrainosus |
Migraine — 5 diagnoses (applies to J3032)
Diseases of the nervous system (5)
| ICD-10 | Covered diagnosis |
|---|---|
| G43.001 | Migraine without aura, not intractable, with status migrainosus |
| G43.011 | Migraine without aura, intractable, with status migrainosus |
| G43.019 | Migraine without aura, intractable, without status migrainosus |
| G43.901 | Migraine, unspecified, not intractable, with status migrainosus |
| G43.911 | Migraine, unspecified, intractable, with status migrainosus |
What commercial payers require for Vyepti
Medicare Part B is only half the answer — most Vyepti claims are adjudicated by a commercial plan with its own medical policy. Below is what 28 commercial payers publish for Vyepti, read from each payer's own policy document. 20 of 28 that state a position require prior authorization, and 13 run a site-of-care program that can push the infusion out of the hospital outpatient setting.
| Payer | Prior auth | Preferred product first | Site of care | Indications named | Policy date |
|---|---|---|---|---|---|
| Aetna policy ↗ | Required | — | Site of Care Utilization Management Policy applies for eptinezumab-jjmr (Vyepti). | 1 | 2025-12-09 |
| Anthem / Elevance policy ↗ | Required | — | Vyepti is an infused agent that requires administration via healthcare professional every 3 months | 1 | 2024-03-15 |
| Arkansas BCBS policy ↗ | Required | — | Please refer to a separate policy on Site of Care or Site of Service Review policy #2018030 for pharmacologic/biologic medications. | 1 | 2025-07-09 |
| BCBS Federal Employee Program policy ↗ | Required | — | — | 1 | 2025-07-01 |
| BCBS Kansas policy ↗ | Not required | — | Site-of-care program applies | 1 | — |
| BCBS Louisiana policy ↗ | Not required | — | — | 1 | 2026-07-01 |
| BCBS Massachusetts policy ↗ | Required | — | — | 1 | — |
| BCBS Michigan policy ↗ | Required | — | Site-of-care program applies | 1 | 2025-10-09 |
| BCBS Minnesota policy ↗ | Required | — | — | 1 | 2025-12-02 |
| BCBS Nebraska policy ↗ | Required | — | — | 1 | 2025-11-05 |
| BCBS South Carolina policy ↗ | Not required | — | — | 1 | — |
| BCBS Tennessee policy ↗ | Required | — | — | 1 | 2020-06-02 |
| Blue Shield of California policy ↗ | Required | — | preferred site of service for certain plans | 1 | 2026-02-01 |
| Capital BlueCross policy ↗ | Required | — | — | 1 | 2025-12-02 |
| CareFirst BCBS policy ↗ | Required | — | outpatient hospital setting reserved for specific clinical exceptions (e.g., severe venous access issues) | 1 | — |
| Centene / Ambetter policy ↗ | Required | — | — | 1 | 2026-01-01 |
| Cigna policy ↗ | Required | — | — | 1 | 2026-06-01 |
| Excellus BCBS policy ↗ | Required | — | site of care may affect approval timeframe and is subject to review | 1 | 2026-06-01 |
| Florida Blue policy ↗ | Required | — | additional requirements may apply if administered in a hospital-affiliated outpatient setting; refer to Site of Care Policy 09-J3000-46 | 1 | 2026-07-01 |
| HCSC (IL/TX/OK/NM/MT) policy ↗ | Not required | — | Site-of-care program applies | 1 | 2025-01-01 |
| Highmark BCBS policy ↗ | Required | — | Restricted to non-hospital-affiliated physician office, non-hospital-affiliated specialized infusion center, or home; hospital outpatient facility only if member meets medically-unstable exception criteria | 1 | 2021-02-01 |
| HMSA (BCBS Hawaii) policy ↗ | Required | — | — | — | 2026-06-12 |
| Horizon BCBS NJ policy ↗ | Required | — | — | 1 | 2020-09-11 |
| Independence Blue Cross policy ↗ | Not required | — | — | 1 | 2026-04-06 |
| Premera Blue Cross policy ↗ | Not required | — | Vyepti is subject to site of service medical necessity review | 1 | 2026-04-01 |
| Regence BCBS policy ↗ | Not required | — | Site-of-care program applies | 1 | — |
| UnitedHealthcare policy ↗ | Required | — | — | 1 | 2025-09-01 |
| Wellmark BCBS policy ↗ | Not required | — | — | 1 | 2026-06-01 |
What Vyepti payers put in writing
Quoted from the medical policies linked above — 24 distinct requirements across 28 payers. These are the sentences an appeal has to answer.
Clinical prerequisites — what must be true before they pay
Trial and failure (after a trial of at least three months), contraindication, or intolerance to formulary approved CGRP self-injectable migraine therapies.
— BCBS Kansas, Regence BCBS, UnitedHealthcare policy ↗Patient is 18 years of age or older
— BCBS Kansas, BCBS Louisiana, Regence BCBS policy ↗Patient has greater than or equal to 15 headache days per month, of which at least 8 must be migraine days
— BCBS Kansas, Regence BCBS policy ↗Medication will not be used in combination with another injectable CGRP inhibitor for prevention.
— BCBS Kansas, BCBS South Carolina policy ↗Patient has ≥ 4 migraine headache days per month
— BCBS Massachusetts, Cigna policy ↗Patient is ≥ 18 years of age
— BCBS Massachusetts, Cigna policy ↗
Prior authorization
Precertification of Vyepti is required of all Aetna participating providers and members in applicable plan designs.
— Aetna policy ↗Prior Approval is required for Eptinezumab-jjmr (e.g., Vyepti).
— Arkansas BCBS policy ↗Prior approval is required to ensure the safe, clinically appropriate, and cost-effective use of CGRP antagonists IV while maintaining optimal therapeutic outcomes.
— BCBS Federal Employee Program policy ↗Authorization/reauthorization has been previously approved by Florida Blue or another health plan in the past two years for migraine prophylaxis
— Florida Blue policy ↗Line of Business PA Required in Medical Management System (Yes/No) BCBS Yes BCN Yes MAPPO Yes BCNA Yes
— BCBS Michigan policy ↗This form is to be used by participating physicians to obtain coverage for Vyepti.
— BCBS Michigan policy ↗
Quantity and frequency limits
300 billable units every 84 days
— BCBS Minnesota, Capital BlueCross policy ↗Some individuals may benefit from a dosage of 300 mg administered by intravenous infusion every 3 months.
— Aetna policy ↗Vyepti single-dose vial 100 mg/mL 3 vials per 90 days
— BCBS Federal Employee Program policy ↗The intent of the CGRP prior authorization with quantity limit is to encourage appropriate use according to clinical trial data and FDA approved labeling.
— BCBS Nebraska policy ↗300 mg (3 vials) once every 3 months if medical justification for higher dose is
— Centene / Ambetter policy ↗100 mg or 300mg administered by intravenous infusion every 3 months
— Horizon BCBS NJ policy ↗
Dosing rules
Some patients may benefit from a dose of 300 mg every 3 months.
— BCBS Kansas, Regence BCBS policy ↗The recommended dose of eptinezumab-jjmr (e.g., Vyepti) is 100 mg or 300 mg.
— Arkansas BCBS policy ↗If the requested drug is Vyepti, the dose will not exceed 300 mg every 3 months
— BCBS Louisiana policy ↗The recommended dose of Vyepti is 100 mg administered by intravenous infusion every 3 months. However, some patients may benefit from a dosage of 300 mg every 3 months
— BCBS Louisiana policy ↗The recommended dose for Vyepti is 100 mg administered as an intravenous infusion over approximately 30 minutes every 3 months. Some patients may benefit from a dose of 300 mg every 3 months. According to the manufacture
— BCBS South Carolina policy ↗Approve up to 300 mg administered by intravenous infusion once every 3 months.
— Cigna policy ↗
Read from each payer's published medical policy between 2026-08-03 and 2026-08-13. Every requirement above is quoted from the policy it links to. Commercial policy changes without notice — confirm before you bill.
How to bill Vyepti
Put a medically necessary, FDA-indicated diagnosis from the list above on the claim line with J3032. Matching codes, units and JZ/JW wastage →
Which policy governs Vyepti
No drug-specific LCD or Article — see the note at the top of this page. Find your MAC → What an LCD, an Article and an NCD each govern →
If a claim for Vyepti is denied
With no drug-specific Article, the usual cause is a diagnosis the MAC does not accept as medically necessary for J3032, or an off-label use with no compendium support. The five denial patterns and how to fix each →
Frequently asked questions
- Is Vyepti covered by Medicare?
- Yes. Vyepti (J3032) is covered under Medicare Part B as a physician-administered drug when billed for a medically necessary indication. There is no drug-specific Local Coverage Determination (LCD) for it, so coverage is determined per medical necessity by your MAC; the FDA-approved indications below are the starting point.
- What diagnoses are covered for Vyepti (J3032)?
- Medicare publishes no drug-specific covered-diagnosis list for J3032. The 13 ICD-10 codes here are the FDA-approved indications; an off-label use needs approved-compendium support (DrugDex, NCCN) to be payable.
- Which Medicare policy covers Vyepti?
- No drug-specific LCD or Billing & Coding Article exists for Vyepti. It's covered under the general Medicare Part B drug benefit per medical necessity, as judged by your Medicare Administrative Contractor (MAC).
- Why was my Vyepti claim denied as not medically necessary?
- The most common cause is a diagnosis the MAC doesn't consider medically necessary for J3032. Bill a covered/FDA-approved indication from the list below, document medical necessity, and confirm any local guidance with your MAC.
Related references
Covered is only half the answer.
You know the diagnosis is payable. Now quote the patient before the visit and catch underpayments: get Vyepti's exact Medicare allowed amount, your payer's rate vs. ASP+6%, and the patient's out-of-pocket — in about 30 seconds, free.
Estimate Vyepti cost & patient owe →Source & verification
- Source
- FDA-approved indications (Drugs@FDA labeling) mapped to ICD-10-CM. No drug-specific Medicare LCD/Article exists for Vyepti — Part B coverage is determined per medical necessity by your MAC.
- Primary sources
- DailyMed — Vyepti prescribing information · CMS Part B Drug ASP Pricing File — the quarterly payment limit quoted above · CMS Medicare Coverage Database — searched for “Vyepti”; no drug-specific NCD, LCD or Billing & Coding Article exists, which is why the FDA-indicated codes above are the working list
- Page last reviewed by CareCost
- Aug 23, 2026 (coverage data retrieved 2026-08-26; we re-verify against CMS quarterly).
- Code licensing
- ICD-10-CM codes are public domain (CMS/CDC). CPT® codes are AMA-copyrighted and are intentionally not listed here — see the administration-code reference for those.
- Not advice
- This is general billing reference, not legal or billing advice. Always verify against the LCD/Article that applies to your MAC and patient.
- How we build this
- Compiled programmatically from the CMS Coverage API under a founder-led methodology maintained by Erin Rose (Founder), and reviewed against the source article with a practitioner-correction loop. See our methodology and editorial policy.
- Spotted an error?
- Email editorial@carecostestimate.com.