The VYEPTI CONNECT enrollment form is a single document that signs a patient up for Lundbeck’s support program for Vyepti (eptinezumab-jjmr), covering benefits investigation, copay assistance, and infusion coordination. You and your prescriber each complete a section, then the finished form goes to VYEPTI CONNECT by fax at 866-868-7071 or through the online prescriber portal at portal.trialcard.com/lundbeck/vyepti/. The same form handles brand-new patients and anyone continuing therapy, so there is no separate renewal document.
What You Fill In as the Patient
The top of the form is demographics. First name, middle initial, last name, date of birth, and sex (marked M or F). Street address, city, state, ZIP, and a preferred phone number. The online version adds a field for email. Every field marked with an asterisk is required, and skipping one will delay processing.
A checkbox asks whether you are new to Vyepti. Mark yes or no so the program knows whether to set you up as a first-time patient or process the enrollment as a continuation.
Medical and Pharmacy Insurance
The insurance block has two parts that are easy to mix up. Both matter, because Vyepti is a physician-administered infusion and different plans route the cost through different benefit categories.
For medical insurance, enter the primary carrier’s name, the carrier’s phone number, your member ID, and your group ID. If the policy is in someone else’s name, write in the policyholder’s full name, their relationship to you, and their date of birth. A secondary insurance block repeats the same fields and should only be filled in if you carry a second medical plan.
The pharmacy insurance section asks for the insurance name, policy ID, group ID, Rx BIN, and Rx PCN. Those numbers appear on the pharmacy side of your insurance card, often on the back. Rx BIN and Rx PCN are routing codes that send claims to the correct processor. If your plan doesn’t separate medical and pharmacy benefits, your provider’s office can help you work out which fields apply.
Signing the Patient Authorization
Before Lundbeck can look into your coverage or enroll you in any financial assistance program, you have to sign the Patient Authorization. Your signature lets your healthcare providers and health plans share your personal health information with Lundbeck and its service providers, so the program can check benefit eligibility, talk to your providers about coverage, coordinate infusions, and send you support materials.
The authorization also notes that once your information is disclosed to Lundbeck, federal privacy protections may no longer restrict how it is further disclosed. The permitted uses go beyond getting your medication approved and include program evaluation and general business purposes, so read the section before you sign. Without a valid signature and date, nothing moves forward. California patients may also need to complete a separate state-specific consent form.
What the Prescriber’s Office Fills In
The prescriber section is handled by your doctor or their staff. Required fields include the prescriber’s first and last name, NPI number, Tax ID, office name, and phone number. These identifiers confirm the clinician is licensed and let the program coordinate on benefits and prior authorization paperwork.
A separate block covers the infusion provider, which may or may not be the same as the prescriber’s office. The form asks for the site of infusion, chosen from four options: physician office, home infusion, infusion center, or hospital outpatient. The infusion provider’s name, full address, contact name, phone, fax, and Tax ID are all required. If your insurer requires a specific type of facility or an in-network provider, confirm the right location before the form goes out. A mismatch here can trigger a coverage denial before treatment ever starts.
The prescription portion captures the Vyepti order itself: dosage (100 mg or 300 mg), quantity of vials, number of refills, the SIG, and the primary ICD-10-CM diagnosis code. At the bottom, the Prescriber Certification and Authorization section requires a separate printed name, signature, and date from the prescriber. That signature is different from the prescription signature above it, and both are required.
How To Submit It
Two channels are available:
- Fax the completed form to 866-868-7071. This is the method most provider offices use and it is printed directly on the form.
- Submit electronically through the prescriber portal at portal.trialcard.com/lundbeck/vyepti/. This route tends to be faster because it skips scanning and avoids handwriting problems.
For questions before or after you send the form, call 833-4-VYEPTI (833-489-3784), Monday through Friday, 8 AM to 8 PM Eastern.
What Happens After You Send It
Once the form arrives, the program runs a benefits investigation, contacting your insurer directly to pin down your copay, coinsurance, deductible status, and annual out-of-pocket maximum. It also identifies whether your plan requires prior authorization before Vyepti can be administered.
Prior authorization requirements vary widely. Some insurers want documentation of monthly migraine days, a list of preventive medications you have already tried, and evidence that earlier treatments either didn’t work or caused intolerable side effects. Plans may also impose step therapy, meaning you need to have tried and failed certain preferred medications before Vyepti will be approved. Your prescriber’s office should have chart notes and medication history ready.
The program will notify both you and your provider’s office of the enrollment status and benefits findings. If your plan participates in the VYEPTI Infusion Network, expect a welcome call from the assigned infusion provider, often from an unrecognized number.
Copay Assistance and Who Qualifies
Patients with commercial insurance may qualify for the VYEPTI CONNECT Copay Assistance Program, which can bring your cost down to as little as $0 per infusion. The program also covers up to $200 per infusion toward administration fees, which the infusion facility bills separately from the drug itself. A calendar-year maximum caps total program assistance across medication and administration costs combined.
The copay program is not available if your prescription can be reimbursed, in whole or in part, by any government healthcare program. That includes Medicare, Medicaid, Veterans Administration, Department of Defense, and TRICARE. If you fall into one of those categories, Lundbeck operates a separate patient assistance program that may help. Ask when you call the VYEPTI CONNECT line, or have your provider point you to it through Lundbeck’s website.
Patients without any insurance coverage will be responsible for both the medication cost and the infusion administration fee, and those fees vary significantly by facility and region. If cost is a concern, raise it with your prescriber’s office before the enrollment form is submitted so the support team can route you to the right resources from the start.
Common Mistakes That Delay Enrollment
Most problems come down to incomplete paperwork. A few things trip people up regularly:
- Transposed insurance numbers. Check your member ID and group ID against the card itself. One wrong digit forces the program to request corrected information, adding days to the process.
- Missing pharmacy insurance. Many patients fill out the medical block and leave the pharmacy fields blank. If your plan has separate pharmacy benefits, that gap complicates the benefits investigation.
- An unsigned authorization. The patient signature and the prescriber signature are both required. If either is missing, the form comes back before any work begins.
- Wrong infusion site details. Confirm the infusion location with your insurer before submitting. Listing a facility your plan won’t cover leads to a denial.
Attaching a copy of your insurance card, front and back, along with chart notes covering medication history, lets the program start the benefits investigation without a round of follow-up requests.