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    v1.0.28
    OpenPayerPolicy UpdatesPsychiatry/Behavioral HealthCareSource Georgia Spravato Coverage | OpenPayer
    Ask Trek AI about this page
    CurrentCareSource GeorgiaPolicy GA-MED-P-366579

    Spravato (esketamine) Coverage Criteria

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    This policy governs prior authorization and coverage of Spravato (esketamine) for adults with major depressive disorder with acute suicidal ideation or behavior, or treatment-resistant major depressive disorder. It applies to CareSource Georgia Medicaid pharmacy or medical benefit billing.

    Policy Summary
    PayerCareSource Georgia
    PolicySpravato (esketamine) Coverage Criteria
    Policy CodePolicy GA-MED-P-366579
    Change TypeMaterial revision
    Effective DateFebruary 1, 2026
    Last ReviewFeb 11, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization for Spravato through the pharmacy or medical benefit before treatment.
    SourceLink
    POLICY UPDATE CHANGES

    The requirement that Spravato for treatment-resistant depression be used with an oral antidepressant was removed because the labeling permits monotherapy.

    Treatment-resistant depression induction dosing was revised to match the product labeling.

    The billing code for Spravato was updated to S0013.

    18+Minimum member age
    2Failed oral antidepressants required
    8 weeksMinimum trial duration per antidepressant

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    1 monthInitial approval for acute suicidal ideation
    2 monthsInitial approval for treatment-resistant depression
    6 monthsAdditional reauthorization period

    Coverage Criteria

    MDD with suicidal ideation or behavior — initial authorization

    Covered for initial authorization when ALL of the following are met.

    MDD with acute suicidal ideation or behavior

    • ALL of the following

      • Member is at least 18 years of age.At least 18 years
      • Medication is prescribed by a psychiatrist in a Spravato REMS-certified center.
      • Member has a diagnosis of major depressive disorder with documented acute suicidal ideation or behavior requiring immediate intervention.
      • Medication is used in conjunction with an oral antidepressant.
      • Dosage is 84 mg (1 kit) twice per week for 4 weeks, for a total of 8 kits.84 mg twice per week for 4 weeks; 8 kits total

    MDD with suicidal ideation — reauthorization

    Reauthorization rule.

    Continuation of the same suicidal ideation episode

    • Continuation of Spravato beyond 4 weeks has not been established for the same episode.4 weeks

      If this is a new suicidal ideation episode, the initial authorization criteria must be followed.

    Treatment-resistant depression — initial authorization

    Covered for initial authorization when ALL of the following are met.

    Treatment-resistant depression

    • Member is at least 18 years of age.At least 18 years
    • Medication is prescribed by a psychiatrist in a Spravato REMS-certified center.
    • Member has a diagnosis of treatment-resistant major depressive disorder.

    • ALL of the following

      • Qualifying antidepressant classes

        • Selective serotonin reuptake inhibitor, such as citalopram or fluoxetine.

    Treatment-resistant depression — reauthorization

    Reauthorization requires ALL of the following.

    Treatment response

    • Documented improvement in depressive symptoms is demonstrated using an appropriate rating scale, such as PHQ-9 or BDI.Improvement on an appropriate depression rating scale

      If the reauthorization requirement is met, approval is granted for an additional 6 months.

    Conditions or indications not listed in this policy are excluded from medical necessity consideration under this policy. Requests for other indications should be directed to the applicable Off-Label policy.

    Spravato is considered not medically necessary for the treatment of conditions that are not listed in this document.

    Coding and Dosing Parameters

    Billing CodeHCPCS
    S0013Spravato (esketamine)
    Minimum Age
    Minimum ageAt least 18 years
    Applies toAdult members seeking initial authorization for Spravato
    RequirementThe member must be at least 18 years of age
    MDD With Suicidal Ideation Dosage
    Dose84 mg (1 kit)
    Frequency and durationTwice per week for 4 weeks
    Total quantity8 kits total

    Provider Actions and Authorization Guidance

    Prior Authorization

    Prior Authorization Required

    Spravato requires prior authorization through the pharmacy or medical benefit before coverage. The applicable billing code is S0013.

    Prior Authorization

    Acute Suicidal Ideation: Initial Authorization

    For acute suicidal ideation or behavior associated with major depressive disorder, initial authorization covers 1 month when all requirements are met. The allowed dosage is 84 mg (1 kit) twice per week for 4 weeks, for a total of 8 kits.

    • If the member also has concomitant treatment-resistant depression, the treatment-resistant depression criteria must be met for a longer approval duration.
    Prior Authorization

    Treatment-Resistant Depression: Initial Authorization

    For treatment-resistant depression, initial authorization is approved for 2 months when all requirements are met. The policy allows induction and maintenance dosing of 56 mg or 84 mg as specified below.

    Policy Background

    Spravato (esketamine) is a noncompetitive N-methyl-D-aspartate receptor antagonist. This policy addresses its use in adults with treatment-resistant major depressive disorder and in adults with major depressive disorder accompanied by acute suicidal ideation or behavior. Treatment-resistant depression requires failure of adequate trials of multiple oral antidepressants, while the acute suicidal ideation or behavior indication requires concurrent oral antidepressant therapy.

    Definitions

    Spravato (Esketamine)
    MedicationSpravato (esketamine)
    Drug classNoncompetitive N-methyl-D-aspartate (NMDA) receptor antagonist
    Covered indicationsTreatment-resistant depression in adults, as monotherapy or with an oral antidepressant, and depressive symptoms associated with major depressive disorder with acute suicidal ideation or behavior in conjunction with an oral antidepressant
    MDD With Suicidal Ideation
    ConditionMajor depressive disorder (MDD)
    Required presentationDocumented acute suicidal ideation or behavior
    Clinical need
    Policy Summary
    PayerCareSource Georgia
    PolicySpravato (esketamine) Coverage Criteria
    Policy CodePolicy GA-MED-P-366579
    Change TypeMaterial revision
    Effective DateFebruary 1, 2026
    Last ReviewFeb 11, 2025
    Next Review DateN/A
    Key ActionObtain prior authorization for Spravato through the pharmacy or medical benefit before treatment.
    SourceLink
    On This Page
    Coverage CriteriaCoding and Dosing ParametersProvider Actions and Authorization GuidancePolicy BackgroundDefinitions
  1. Selective norepinephrine reuptake inhibitor, such as duloxetine or venlafaxine.
  2. Tricyclic antidepressant, such as nortriptyline.
  3. Monoamine oxidase inhibitor, such as tranylcypromine.
  4. Bupropion.
  5. Mirtazapine.
  6. Baseline depression status is documented using an appropriate rating scale, such as PHQ-9, BDI, QIDS, MADRS, or HAM-D.
  7. Dosing follows the policy schedule: weeks 1 through 4, twice per week at 56 mg or 84 mg; weeks 5 through 8, once weekly at 56 mg or 84 mg; and week 9 and after, every 2 weeks or once weekly at 56 mg or 84 mg.

    From week 9 onward, individualize dosing to the least frequent frequency that maintains remission or response.

    8. Failed Antidepressant Trials
    Number of trialsAt least 2 oral antidepressants
    Class and durationThe trials must be from different drug classes, at optimized doses for at least 8 weeks
    Required classAt least 1 trial must be from the SSRI or SNRI class
    Treatment-Resistant Depression: Induction
    Induction periodWeeks 1–4
    FrequencyAdminister twice per week
    Dose options56 mg or 84 mg
    Treatment-Resistant Depression: Maintenance Weeks 5–8
    Maintenance periodWeeks 5–8
    FrequencyAdminister once weekly
    Dose options56 mg or 84 mg
    Treatment-Resistant Depression: Week 9 and After
    Maintenance periodWeek 9 and after
    Frequency optionsAdminister every 2 weeks or once weekly
    Dose options56 mg or 84 mg
    IndividualizationUse the least frequent dosing that maintains remission or response
    • Weeks 1–4: administer twice per week.
    • Weeks 5–8: administer once weekly.
    • Week 9 and after: administer every 2 weeks or once weekly; individualize to the least frequent dosing that maintains remission or response.
    Step Therapy

    Document Two Failed Antidepressant Trials

    Document failure of at least two qualifying oral antidepressant trials from different drug classes at optimized doses for at least 8 weeks. At least one failed trial must be an SSRI or SNRI.

    • Qualifying options include an SSRI, such as citalopram or fluoxetine; an SNRI, such as duloxetine or venlafaxine; a tricyclic antidepressant, such as nortriptyline; a monoamine oxidase inhibitor, such as tranylcypromine; bupropion; or mirtazapine.
    Documentation Required

    Acute Suicidal Ideation Documentation

    For acute suicidal ideation or behavior, document the clinical information supporting initial authorization and the required treatment setting.

    • Member is at least 18 years of age.
    • Spravato is prescribed by a psychiatrist in a Spravato REMS-certified center.
    • Member has a diagnosis of major depressive disorder with acute suicidal ideation or behavior requiring immediate intervention.
    • Document use with an oral antidepressant as specified in the policy criteria.
    Documentation Required

    Treatment-Resistant Depression Documentation

    For treatment-resistant depression, document the member’s eligibility, treatment setting, diagnosis, failed antidepressant trials, and baseline depression status before requesting initial authorization.

    • Member is at least 18 years of age.
    • Spravato is prescribed by a psychiatrist in a Spravato REMS-certified center.
    • Member has a diagnosis of treatment-resistant major depressive disorder.
    • Document at least two failed qualifying oral antidepressant trials from different drug classes at optimized doses for at least 8 weeks, including at least one SSRI or SNRI.
    • Document baseline depression status using an appropriate depression rating scale.
    Documentation Required

    Acceptable Depression Scales

    Use an appropriate validated depression rating scale to document baseline status for treatment-resistant depression and to support treatment assessment.

    • Patient Health Questionnaire (PHQ-9)
    • Beck Depression Inventory (BDI)
    • Quick Inventory of Depressive Symptomatology (QIDS)
    • Montgomery-Åsberg Depression Rating Scale (MADRS)
    • Hamilton Rating Scale for Depression (HAM-D)
    Documentation Required

    Reauthorization Response Documentation

    For reauthorization of treatment-resistant depression, document improvement in depressive symptoms using an appropriate depression rating scale.

    • Examples include PHQ-9, BDI, QIDS, MADRS, and HAM-D.
    • When reauthorization requirements are met, approval may be granted for an additional 6 months.
    Denial Risk

    Acute Suicidal Ideation Criteria Not Met

    Acute suicidal ideation or behavior authorization is not supported when the initial criteria are not met.

    • Member is under 18 years of age.
    • Prescription is not from a psychiatrist in a Spravato REMS-certified center.
    • Member does not have major depressive disorder with documented acute suicidal ideation or behavior requiring immediate intervention.
    • Required oral antidepressant use is not documented under the policy criteria.
    • Required clinical documentation or dosing requirements are not satisfied.
    Denial Risk

    Treatment-Resistant Depression Criteria Not Met

    Treatment-resistant depression authorization is not supported when the required clinical, prescribing, treatment-history, or documentation criteria are not met.

    • Member is under 18 years of age.
    • Prescription is not from a psychiatrist in a Spravato REMS-certified center.
    • Member does not have treatment-resistant major depressive disorder.
    • At least two qualifying failed oral antidepressant trials from different drug classes are not documented, or at least one is not an SSRI or SNRI.
    • Baseline depression status is not documented using an appropriate rating scale.
    Denial Risk

    Continuation of Suicidal-Ideation Episode

    Continuation of Spravato beyond 4 weeks has not been established for the same acute suicidal ideation episode. A new suicidal ideation episode must satisfy the initial authorization criteria.

    Denial Risk

    Unlisted Indication

    Spravato is not medically necessary for conditions or indications not listed in this policy.

    • For any other indication, refer to the applicable Off-Label policy.
    The suicidal ideation or behavior must require immediate intervention
    Treatment-Resistant Depression
    ConditionTreatment-resistant major depressive disorder
    Treatment historyFailure of at least 2 qualifying oral antidepressants from different drug classes
    Trial requirementsTrials must be at optimized doses for at least 8 weeks, including at least 1 SSRI or SNRI
    Spravato REMS-Certified Center
    DefinitionA center certified under the Spravato Risk Evaluation and Mitigation Strategy (REMS)
    Medication settingThe center is the setting in which Spravato is administered or prescribed
    Prescriber requirementSpravato must be prescribed by a psychiatrist in a Spravato REMS-certified center