CurrentCignaPolicy N/A

Spravato (esketamine) prior authorization form — coverage criteria

Form governing prior authorization requests for Spravato (esketamine) nasal spray, capturing patient, prescriber, clinical history, and treatment justification to support coverage decisions. Affects prescribers and facilities seeking coverage from Cigna for Spravato.

Policy Summary

PayerCigna

PolicySpravato (esketamine) prior authorization form — coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization including documentation of prior antidepressant trials, therapeutic dosing/duration, and supportive clinical notes.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

5 business daysstandard response time

3dose strengths

2indications listed

Coverage Criteria

Initial coverage criteria

Covered when ALL of the following are met

Indication: Prescriber selects either Treatment-Resistant Depression or Major Depressive Disorder with Acute Suicidal Ideation or Behavior

Concomitant therapy: Will/Is Spravato be(ing) used with at least ONE oral antidepressant? (e.g., SSRI, SNRI, TCA, mirtazapine, or bupropion)

Yes/No response required on form

Treatment-resistant specific criteria: For Treatment-Resistant Depression: patient demonstrated nonresponse (defined as \u226425% improvement) to at least TWO different antidepressants, each from a different pharmacologic class>=2 distinct classes; nonresponse <=25% improvement

Each antidepressant must have been used at therapeutic dosages for at least 6 weeks

Policy Summary

PayerCigna

PolicySpravato (esketamine) prior authorization form — coverage criteria

Policy CodePolicy N/A

Change TypeNo material changes

Effective DateN/A

Next Review DateN/A

Key ActionSubmit prior authorization including documentation of prior antidepressant trials, therapeutic dosing/duration, and supportive clinical notes.

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Initial therapy requirements

Initial coverage requires documented prior antidepressant history and plan for concomitant oral antidepressant

Prescriber specialty: Is Spravato being prescribed by, or in consultation with, a psychiatrist?

Yes/No response captured on form

Concomitant oral antidepressant: Will/Is Spravato be(ing) used with at least ONE oral antidepressant?

Form lists SSRIs, SNRIs, TCAs, mirtazapine, and bupropion as examples

Prior antidepressant trials: Has patient previously been treated with antidepressants and demonstrated nonresponse to at least TWO from different pharmacologic classes?>=2 distinct classes; nonresponse <=25% improvement

Each prior antidepressant must have been used at therapeutic dosages for at least 6 weeks; specific drug names, strengths, dates, durations, and documented results (including intolerances) must be provided on the form

Continuation therapy

Continuation therapy covered when ALL of the following are met

Prior approval on record: If continued therapy, confirm a previous approval for the medication is on record

Form asks Yes/No

Documented beneficial response: Documentation the patient has had a beneficial response to Spravato (for example, a 50% or greater reduction in a depression rating scale score from baseline)>=50% improvement

If no documentation of benefit, provide clinical support and state number of Spravato doses already received

Continuation therapy requirements

Continuation requires prior approval and documentation of benefit

Prior approval: Is there a previous approval on record for the medication requested?

Form captures response when request is for continued therapy

Beneficial response: Is there documentation the patient has had a beneficial response (e.g., 50% or greater reduction in a depression rating scale score)?>=50% improvement

If no, submit clinical justification and number of doses already received

Medication & Coding Details

Requested medication optionsNDC | HCPCS (not specified)

Spravato 28mg	Spravato 28mg nasal spray
Spravato 56mg	Spravato 56mg dose kit nasal spray
Spravato 84mg	Spravato 84mg does kit nasal spray

Therapeutic trial duration

Therapeutic trial durationEach antidepressant must be used at therapeutic dosages for at least 6 weeks in the current episode of depression.

Applies to step-therapy requirementThe >=6-week duration requirement applies to each of the at least two antidepressant trials required for treatment‑resistant depression.

Documentation neededForm requires dates taken and how long each antidepressant was taken to verify the >=6-week therapeutic duration.

Step	Requirement
1	Documented nonresponse (defined as 25% or less improvement in depression symptoms or scores) to at least two different antidepressants, each from a different pharmacologic class
	Each antidepressant trial must have been used at therapeutic dosages for at least 6 weeks in the current episode of depression

Provider Actions & Documentation

Prior Authorization

Prior Authorization Required

Prior Authorization Required — submit the completed prior authorization form that collects indication, dose strength requested, duration, quantity, and whether this is a new start or continuation of therapy. For continued therapy, indicate if there is a prior approval on record and document clinical benefit (for example, ≥50% reduction in a depression rating-scale score) or provide clinical rationale for ongoing use and total number of doses received.

Form fields: medication requested, ICD-10, dose kit selection (28mg, 56mg, 84mg), directions, quantity, duration, new start vs continuation, prior approval on record (if continuation)
Attach completed form and ensure all required fields are legible and completed

Step Therapy

Step / Failed‑Therapy Requirements

Step/failed-therapy requirements must be documented. The request must show that the patient demonstrated nonresponse (≤25% improvement in symptoms or scores) to at least TWO different antidepressants from two different pharmacologic classes. Each prior antidepressant trial must have been given at therapeutic dosages for at least 6 weeks in the current episode.

Document the classes and specific agents tried (examples: SSRIs, SNRIs, TCAs, mirtazapine, bupropion)
For each agent include drug name, strength, dates taken, duration, and documented result (nonresponse, intolerance, or adverse reaction)

Documentation Required

Required Supportive Documentation

Required supportive documentation must be attached with the request — include relevant chart notes, depression rating-scale scores, lab and test results, PDMP checks (when required), and consultation notes if applicable. If Spravato is being used, document whether it will be used with at least one oral antidepressant and whether a psychiatrist is prescribing or consulting.

Attach documentation of prior trials: names, strengths, start/stop dates, duration, dose, and clinical outcome
If applicable, include documentation of benefit for continued therapy (e.g., ≥50% reduction in rating-scale score) and number of Spravato doses already administered
Include assessment of risk for abuse (e.g., PDMP query) for treatment‑resistant cases and documentation regarding history of psychosis and prescriber risk‑benefit assessment

Denial Risk

Denial Risk — Missing Documentation

Denial risk if documentation is missing or incomplete. Lack of documentation of prior antidepressant trials (including dosing and duration), absence of supportive clinical records (chart notes, rating scales, lab/test results), or failure to demonstrate required step‑therapy criteria may result in denial of the request.

Common missing items that increase denial risk: absent prior trial details, no dates or durations, no documented therapeutic dosing, missing depression severity/response measures, and no statement of concomitant oral antidepressant therapy when required

Site of Care & Dispensing

Note

Specify site of care and provide facility/dispensing location details

The form asks where the medication will be obtained and collects facility/dispensing location information; it also asks whether the patient is a candidate for home infusion or if the physician has an in‑office infusion site.

Location options on form: prescriber's office stock, retail pharmacy, home health/home infusion vendor, or other (specify)
Facility/doctor dispensing info requested: facility name, state, tax ID, address
Questions about home infusion candidacy and presence of in‑office infusion site (Yes/No)

Definitions

Nonresponse (treatment‑resistant requirement)

Nonresponse definitionNonresponse is defined on the form as 25% or less improvement in depression symptoms or scores to an antidepressant trial.

Application to treatment‑resistant depressionPatient must have demonstrated nonresponse (<=25% improvement) to at least TWO different antidepressants, each from a different pharmacologic class, to meet the treatment‑resistant requirement.

Supporting documentationForm asks for documented results of taking each drug, including dates, duration, and documented outcomes to substantiate nonresponse.

Beneficial response for continuation

Beneficial response thresholdBeneficial response for continued therapy is exemplified on the form as a 50% or greater reduction in a depression rating scale score from baseline.

Continuation documentationFor continuation, the form asks whether there is documentation the patient has had a beneficial response (example: >=50% reduction); if no, clinical support and number of doses received must be provided.

Use in review decisionsA documented >=50% improvement is used to justify continued coverage per the continuation therapy requirements on the form.

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