Billing and Coding Guide for VYEPTI™ (Eptinezumab-Jjmr)

Billing and Coding Guide for VYEPTI™ (eptinezumab-jjmr)

Lundbeck is committed to patient access and providing reimbursement information to support access to VYEPTI throughout the patient journey. Additional information about the billing and coding of VYEPTI can be obtained in the following ways: • VYEPTI CONNECT™ is an optional program that provides information and support to help with reimbursement issues. Once enrolled, you will be assigned a VYEPTI CONNECT Liaison who can be contacted at 833-4-VYEPTI, Monday through Friday, 8 AM - 8 PM EST. • Field Reimbursement Specialists (FRSs) can assist with reimbursement questions over the phone or in person. Contact your Lundbeck representative to be connected to your FRS.

Indication VYEPTI™ is indicated for the preventive treatment of migraine in adults.

Please see the Important Safety Information on page 8. For more information, see the full Prescribing Information, including Patient Information, or go to vyeptihcp.com.

1 Codes That May Help With Billing and Reimbursement Below is a list of codes that may be useful for the billing and reimbursement of VYEPTI™ (eptinezumab-jjmr). It is important to note that the codes listed here are examples only and are not inclusive of all codes that may be applicable. The use of the following codes does not guarantee reimbursement.

Summary of Relevant Codes1 ICD-10-CM Description G43 MIGRAINE G43.0 MIGRAINE WITHOUT AURA G43.00 MIGRAINE WITHOUT AURA, NOT INTRACTABLE 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 G43.1 MIGRAINE WITH AURA G43.10 MIGRAINE WITH AURA, NOT INTRACTABLE G43.101 MIGRAINE WITH AURA, NOT INTRACTABLE, WITH STATUS MIGRAINOSUS G43.109 MIGRAINE WITH AURA, NOT INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.11 MIGRAINE WITH AURA, INTRACTABLE G43.111 MIGRAINE WITH AURA, INTRACTABLE, WITH STATUS MIGRAINOSUS G43.119 MIGRAINE WITH AURA, INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.4 HEMIPLEGIC MIGRAINE G43.40 HEMIPLEGIC MIGRAINE, NOT INTRACTABLE G43.401 HEMIPLEGIC MIGRAINE, NOT INTRACTABLE, WITH STATUS MIGRAINOSUS G43.409 HEMIPLEGIC MIGRAINE, NOT INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.41 HEMIPLEGIC MIGRAINE, INTRACTABLE G43.411 HEMIPLEGIC MIGRAINE, INTRACTABLE, WITH STATUS MIGRAINOSUS G43.419 HEMIPLEGIC MIGRAINE, INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.5 PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION G43.50 PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, NOT INTRACTABLE G43.501 PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, NOT INTRACTABLE, WITH STATUS MIGRAINOSUS G43.509 PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, NOT INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.51 PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, INTRACTABLE G43.511 PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, INTRACTABLE, WITH STATUS MIGRAINOSUS G43.519 PERSISTENT MIGRAINE AURA WITHOUT CEREBRAL INFARCTION, INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.6 PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION G43.60 PERSISTENT MIGRAINE AURA WITH CEREBRAL INFARCTION, NOT INTRACTABLE ICD-10-CM=International Classification of Diseases, Tenth Revision, Clinical Modification.

Lundbeck cannot guarantee payment of any claim. Coding, coverage, and reimbursement may vary significantly by payer, plan, patient, and setting of care. Actual coverage and reimbursement decisions are made by individual payers following the receipt of claims. For additional information, customers should consult with their payers for all relevant coding, reimbursement, and coverage requirements. It is the sole responsibility of the provider to select the proper code and ensure the accuracy of all claims used in seeking reimbursement. All services must be medically appropriate and properly supported in the patient medical record. Important Safety Information CONTRAINDICATIONS • VYEPTI is contraindicated in patients with serious hypersensitivity to eptinezumab-jjmr or to any of the excipients. Reactions have included angioedema. Please see additional Important Safety Information on page 8. For more information, see the full Prescribing Information, including Patient Information, or go to vyeptihcp.com. 2 Summary of Relevant Codes1 (cont’d) ICD-10-CM Description G43.7 CHRONIC MIGRAINE WITHOUT AURA G43.70 CHRONIC MIGRAINE WITHOUT AURA, NOT INTRACTABLE G43.701 CHRONIC MIGRAINE WITHOUT AURA, NOT INTRACTABLE, WITH STATUS MIGRAINOSUS G43.709 CHRONIC MIGRAINE WITHOUT AURA, NOT INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.71 CHRONIC MIGRAINE WITHOUT AURA, INTRACTABLE G43.711 CHRONIC MIGRAINE WITHOUT AURA, INTRACTABLE, WITH STATUS MIGRAINOSUS G43.719 CHRONIC MIGRAINE WITHOUT AURA, INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.8 OTHER MIGRAINE G43.80 OTHER MIGRAINE, NOT INTRACTABLE G43.801 OTHER MIGRAINE, NOT INTRACTABLE, WITH STATUS MIGRAINOSUS G43.809 OTHER MIGRAINE, NOT INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.81 OTHER MIGRAINE, INTRACTABLE G43.811 OTHER MIGRAINE, INTRACTABLE, WITH STATUS MIGRAINOSUS G43.819 OTHER MIGRAINE, INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.82 MENSTRUAL MIGRAINE, NOT INTRACTABLE G43.821 MENSTRUAL MIGRAINE, NOT INTRACTABLE, WITH STATUS MIGRAINOSUS G43.829 MENSTRUAL MIGRAINE, NOT INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.83 MENSTRUAL MIGRAINE, INTRACTABLE G43.831 MENSTRUAL MIGRAINE, INTRACTABLE, WITH STATUS MIGRAINOSUS G43.839 MENSTRUAL MIGRAINE, INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.9 MIGRAINE, UNSPECIFIED G43.90 MIGRAINE, UNSPECIFIED, NOT INTRACTABLE G43.901 MIGRAINE, UNSPECIFIED, NOT INTRACTABLE, WITH STATUS MIGRAINOSUS G43.909 MIGRAINE, UNSPECIFIED, NOT INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.91 MIGRAINE, UNSPECIFIED, INTRACTABLE G43.911 MIGRAINE, UNSPECIFIED, INTRACTABLE, WITH STATUS MIGRAINOSUS G43.919 MIGRAINE, UNSPECIFIED, INTRACTABLE, WITHOUT STATUS MIGRAINOSUS G43.A CYCLICAL VOMITING G43.A0 CYCLICAL VOMITING, NOT INTRACTABLE G43.A1 CYCLICAL VOMITING, INTRACTABLE G43.B OPHTHALMOPLEGIC MIGRAINE G43.B0 OPHTHALMOPLEGIC MIGRAINE, NOT INTRACTABLE G43.B1 OPHTHALMOPLEGIC MIGRAINE, INTRACTABLE

Important Safety Information (cont’d) WARNINGS AND PRECAUTIONS • Hypersensitivity reactions: Hypersensitivity reactions, including angioedema, urticaria, facial flushing, and rash, have occurred with VYEPTI in clinical trials. Most hypersensitivity reactions occurred during infusion and were not serious, but often led to discontinuation or required treatment. Serious hypersensitivity reactions may occur. If a hypersensitivity reaction occurs, consider discontinuing VYEPTI, and institute appropriate therapy. Please see additional Important Safety Information on page 8. For more information, see the full Prescribing Information, including Patient Information, or go to vyeptihcp.com. 3 Additional Codes That May Be Useful

Here are some assigned codes that may be utilized when submitting a claim for VYEPTI™ (eptinezumab-jjmr). Note that when these codes are used, health plans may require additional documentation. VYEPTI CONNECT Liaisons can provide you with any additional documentation. Note also that as payers may have individual coding preferences, Lundbeck recommends verifying the coding policies of health plans.

CPT® Code for VYEPTI Administration CPT® codes consist of 5 characters. They describe medical procedures and services.2 The following CPT code may be appropriate to report IV administration services. Code3 Description 96365 INTRAVENOUS INFUSION, FOR THERAPY, PROPHYLAXIS, OR DIAGNOSIS, INITIAL INFUSION, UP TO 1 HOUR CPT=Current Procedural Terminology.

J-Code (Level II HCPCS Codes) J-codes are a subset of the HCPCS Level II code set mainly used to identify injectable drugs. J-codes typically include drugs that cannot be self-administered and are medically necessary for the treatment of an injury or illness. A J-code may cover the supply, injection, or infusion of a drug or biologic.4 The J-code to identify VYEPTI injection is as follows.

Code5 Description J3032 INJECTION, EPTINEZUMAB-JJMR, 1 MG HCPCS=Healthcare Common Procedure Coding System.

NDC for VYEPTI An NDC is a unique, three-segment number used as a universal product identifier to report drug products.6 The NDC for VYEPTI is as follows. 10-Digit Format7 11-Digit Format for Claims Submission7 Description 67386-130-51 67386-0130-51 CARTON CONTAINING ONE 100 MG/ML SINGLE-DOSE VIAL NDC=National Drug Code.

Important Safety Information (cont’d) ADVERSE REACTIONS • The most common adverse reactions (≥2% and at least 2% or greater than placebo) in the clinical trials for the preventive treatment of migraine were nasopharyngitis and hypersensitivity. Please see additional Important Safety Information on page 8. For more information, see the full Prescribing Information, including Patient Information, or go to vyeptihcp.com. 4 Sample Claim Form CMS 1500 (Physician’s Office) Below is a sample form CMS 1500 with tips on submitting claims for VYEPTI™ (eptinezumab-jjmr).

BOX 21: Diagnosis or Nature of Illness or Injury Record the appropriate ICD-10-CM diagnosis code from the patient’s medical record

BOX 24A: National Drug Code BOX 24D: Procedures, BOX 24G: Ensure you are If line item NDC information is Services, or Supplies billing the correct number required, it will be entered in the Enter the appropriate HCPCS of units administered. shaded area of Box 24A code (VYEPTI J3032), CPT codes, Example: 100 mg and code modifiers for VYEPTI as specified by the payer

BOX 24E: Diagnosis Pointer Record the diagnosis code number from Box 21 that applies to the procedure code indicated in Box 24D

Important Safety Information (cont’d) CONTRAINDICATIONS • VYEPTI is contraindicated in patients with serious hypersensitivity to eptinezumab-jjmr or to any of the excipients. Reactions have included angioedema. Please see additional Important Safety Information on page 8. For more information, see the full Prescribing Information, including Patient Information, or go to vyeptihcp.com. 5 Sample Claim Form CMS 1450 (UB-04; Hospital Outpatient) Below is a sample form CMS 1450 with tips on submitting claims for VYEPTI™ (eptinezumab-jjmr) for outpatient hospital settings only.

BOX 46: Ensure you are billing the correct number of units. Example: 100 mg

BOX 42: Revenue Codes BOX 44: HCPCS/Rate/Health BOX 47: Total Charges Record the revenue codes that Insurance Prospective Enter the total charges for correspond to the HCPCS Payment System Code entire claim code in Box 44 Indicate appropriate CPT and HCPCS codes and modifiers as required by the payer. Example: VYEPTI J3032

BOX 50: Payer Name BOX 51: Health Plan ID Enter the name of the Enter the health plan health plan identification number

BOX 67: Diagnosis Code Enter the appropriate ICD-10-CM code to identify the patient’s diagnosis

Please see additional Important Safety Information on page 8. For more information, see the full Prescribing Information, including Patient Information, or go to vyeptihcp.com. 7 Support Throughout the Reimbursement Process

VYEPTI CONNECT™ is an optional program that provides information and support for reimbursement issues. Once enrolled, you will be assigned a VYEPTI CONNECT Liaison who can be contacted at 833-4-VYEPTI, Monday through Friday, 8 AM - 8 PM EST, to assist with reimbursement questions. Field Reimbursement Specialists can assist with reimbursement questions over the phone or in person. Contact your Lundbeck representative to be connected to your FRS.

Indication VYEPTI™ is indicated for the preventive treatment of migraine in adults. Important Safety Information CONTRAINDICATIONS • VYEPTI is contraindicated in patients with serious hypersensitivity to eptinezumab-jjmr or to any of the excipients. Reactions have included angioedema.

WARNINGS AND PRECAUTIONS • Hypersensitivity reactions: Hypersensitivity reactions, including angioedema, urticaria, facial flushing, and rash, have occurred with VYEPTI in clinical trials. Most hypersensitivity reactions occurred during infusion and were not serious, but often led to discontinuation or required treatment. Serious hypersensitivity reactions may occur. If a hypersensitivity reaction occurs, consider discontinuing VYEPTI, and institute appropriate therapy.

ADVERSE REACTIONS • The most common adverse reactions (≥2% and at least 2% or greater than placebo) in the clinical trials for the preventive treatment of migraine were nasopharyngitis and hypersensitivity.

For more information, see the accompanying full Prescribing Information, including Patient Information, or go to vyeptihcp.com.

References: 1. ICD10Data website. https://www.icd10data.com/ICD10CM/Codes/G00-G99/G40-G47/G43-. Accessed July 24, 2020. 2. What is CPT®? AAPC website. https://www.aapc.com/resources/medical-coding/cpt.aspx. Accessed July 24, 2020. 3. BioPortal website. http://bioportal.bioontology.org/ ontologies/CPT?p=classes&conceptid=96365. Accessed July 24, 2020. 4. HCPCS website. https://hcpcscodes.org/jcodes. Accessed July 24, 2020. 5. AAPC website. https://coder.aapc.com/hcpcs-codes/J3490. Accessed July 24, 2020. 6. National Drug Code Directory. FDA website. https://www.fda.gov/ drugs/drug-approvals-and-databases/national-drug-code-directory. Accessed July 24, 2020. 7. VYEPTI [package insert]. Bothell, WA. Lundbeck.