Codes & NDC
| HCPCS | J3032 — "Inj, eptinezumab-jjmr, 1 mg" (permanent, eff. 4/1/2021; pre-2021 used J3490 / J3590) |
|---|
| NDC | 00187-1530-91 — N4 qualifier, ML uom, qty 1 (100 mg) or 3 (300 mg) |
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| Vial | 100 mg / 1 mL (100 mg/mL) single-dose — must dilute in 100 mL 0.9% NaCl |
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| Manufacturer | H. Lundbeck A/S (Lundbeck Inc., labeler 00187) |
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| Benefit | Medical (Part B / buy-and-bill) — not specialty pharmacy |
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Dosing
- 100 mg IV q3 months (recommended starting dose) — 1 vial, bill 100 units
- 300 mg IV q3 months (some patients may benefit) — 3 vials, bill 300 units
- 4 infusions / year — major adherence advantage vs monthly SC anti-CGRPs
- Infusion time: ~30 minutes (gravity or pump)
- No loading dose · no weight-based or renal/hepatic adjustment
- Year-1 totals: 400 units (100 mg) or 1,200 units (300 mg)
IV Vyepti vs. SC anti-CGRPs — key biller decision
| Drug | Route | Benefit | HCPCS |
|---|
| Vyepti (Lundbeck) | IV q3 mo | Part B medical | J3032 |
| Aimovig (Amgen/Novartis) | SC monthly | Part D pharmacy | J3031 / Pt D |
| Ajovy (Teva) | SC monthly OR quarterly | Part D pharmacy | J3245 / Pt D |
| Emgality (Lilly) | SC monthly + 240 mg load | Part D pharmacy | J3590 / Pt D |
Vyepti is the only IV anti-CGRP. Bills under medical benefit (CMS-1500). The SC anti-CGRPs go through pharmacy benefit. Different PA pathway, different patient OOP calculation.
Administration & modifiers
| Code | When |
|---|
96365 | Primary — therapeutic IV, ~30 min (non-chemo) |
96366 | Each additional hour (rare for Vyepti) |
96413 / 96415 | NOT appropriate — chemo admin codes |
96372 | NOT appropriate — Vyepti is not an injection |
Common error: billing 96413 (chemo IV) or 96372 (SC/IM injection). Vyepti is a non-chemo biologic that must be diluted in 100 mL 0.9% NaCl and infused — use 96365 (and 96366 only if >1 hr).
JZ on virtually every claim. 100 mg dose = 1 vial, no waste. 300 mg dose = 3 vials, no waste. JW only in rare partial-vial scenarios. One of JZ/JW required since 7/1/2023.
ICD-10 — migraine (G43.x)
| Code | For |
|---|
G43.001 / G43.009 | Migraine without aura, episodic |
G43.011 / G43.019 | Migraine without aura, intractable |
G43.101 / G43.109 | Migraine with aura, episodic |
G43.111 / G43.119 | Migraine with aura, intractable |
G43.701 / G43.709 | Chronic migraine w/o aura |
G43.711 / G43.719 | Chronic migraine, intractable |
G43.901 / G43.911 / G43.919 | Migraine, unspecified (avoid if possible) |
Distinguish chronic vs episodic. Many payers have separate PA criteria; chronic (≥15 headache days/mo) may unlock different doses or step rules.
Payer step therapy (May 2026)
| Payer | PA | Step requirement |
|---|
| UnitedHealthcare | Yes | ≥2 oral preventives + ≥1 SC anti-CGRP, ≥8-wk trials |
| Aetna | Yes | ≥2 oral preventives + SC anti-CGRP; chronic may need Botox trial |
| BCBS plans | Yes | Aligned with commercial step norm; verify per plan |
| Medicare Part B FFS | No | No federal step therapy; covers per FDA label + ICD-10 |
| Medicare Advantage | Often | May impose Part B step therapy (CMS 2018 authority) |
Document everything: Dx, baseline MMD/MHD, oral prophylactic agents tried (≥2 classes, ≥8 wk each, reason discontinued), SC anti-CGRP trial (≥3 monthly doses or 1 quarterly).
Medicare reimbursement (Q2 2026)
| Field | Value |
|---|
| ASP + 6% | $20.546 / mg (effective 4/1 – 6/30/2026) |
| 100 mg dose | $2,054.60 (100 × $20.546) |
| 300 mg dose | $6,163.80 (300 × $20.546) |
| Annual 100 mg (4 doses) | ~$8,218 |
| Annual 300 mg (4 doses) | ~$24,655 |
Site of care
| Setting | POS | Notes |
|---|
| Physician office (neurology) | 11 | Preferred — 30 min fits cleanly |
| Ambulatory infusion center | 49 | Preferred |
| Hospital outpatient | 19/22 | UHC/Aetna disfavor for routine maintenance |
| Patient home (Coram/SDS/Option Care) | 12 | Where payer permits home infusion |
Patient assistance — Vyepti Connect
- Phone: 1-833-389-3784 (Vyepti Connect)
- Commercial copay: $0 per infusion, up to $20,000/year
- PAP: free product for uninsured / underinsured
- Foundations (Medicare): PAN, HealthWell, Good Days — verify open migraine funds
- Web: vyepti.com · HCP: vyeptihcp.com
NO Boxed Warning. W&P only: hypersensitivity reactions (urticaria, angioedema, anaphylaxis), nasopharyngitis, fatigue. Anaphylaxis precautions advised — epinephrine availability, observation period. Premedication NOT routinely required.
Pending SME review. Verify cited sources (FDA label, CMS Q2 2026 ASP, Lundbeck Vyepti Connect, UHC/Aetna policies) for high-stakes claims until the CareCost editorial team sign-off is complete.