Spravato (esketamine) is an intranasal NMDA receptor antagonist indicated for adults for two distinct indications: treatment‑resistant depression (TRD) — as monotherapy or in conjunction with an oral antidepressant — and for depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior when used in combination with an oral antidepressant. Prior authorization is required under the pharmacy benefit for Commercial/Exchange members, and Spravato is designated as a specialty product that must be dispensed at a contracted specialty pharmacy.
Spravato carries a boxed warning for risks including sedation, dissociation, respiratory depression, abuse and misuse, and suicidal thoughts and behaviors. It is only available through a REMS program; per REMS requirements Spravato must be administered under the direct supervision of a healthcare provider and patients must be monitored by a healthcare provider for at least two hours after each administration.
For the MDD with acute suicidal ideation or behavior indication the policy requires the member be ≥ 18 years of age, have the diagnosis of MDD with suicidal ideation or behavior, have a mental health specialist prescriber (or consultation notes), prescriber attestation of supervised administration, and concomitant use of an oral antidepressant. For TRD the policy requires the member be ≥ 18 years, have TRD, a mental health specialist prescriber (or consultation notes), prescriber attestation of supervised administration, and documented inadequate response or adverse reaction to one SSRI and one other non‑SSRI antidepressant, plus either inadequate response to one augmentation strategy (second‑generation antipsychotic, lithium, a second antidepressant from a different class, or thyroid hormone) or a documented contraindication to all augmentation strategies.
Authorization durations differ by indication: initial approvals for TRD are for 3 months with reauthorizations granted for 12 months, while treatment for MDD with acute suicidal ideation or behavior is authorized for 1 month. The recommended acute suicidal ideation dosing is 84 mg twice weekly for 4 weeks (with the option to reduce to 56 mg twice weekly for tolerability), and therapeutic benefit should be reassessed after the 4‑week acute course to determine need for continued treatment.