CurrentMass General Brigham Health PlanPolicy N/A

Spravato (esketamine) — Medical Benefit Prior Authorization

Defines prior authorization criteria, limitations, and continuation requirements for Spravato (esketamine) administered under the medical benefit for MassHealth members; affects prescribers, facility providers, and pharmacy/medical reviewers.

Policy Summary

PayerMass General Brigham Health Plan

PolicySpravato (esketamine) — Medical Benefit Prior Authorization

Policy CodePolicy N/A

Change TypeClarificationseparation into standalone policyreference updates

Effective Date09/01/2025

Next Review Date

Key ActionObtain prior authorization and submit medical records documenting diagnosis, specialist prescriber or consult notes, and required prior antidepressant trials as specified.

SourceLink

POLICY UPDATE CHANGES

Clarified the criteria point regarding concomitant use of an augmenting agent plus antidepressant therapy.

Separated Spravato criteria into its own medical policy distinct from the broader Antidepressants policy and expanded examples of specialists included in criteria.

Updated references and formatting as part of the annual UM review.

≥18minimum member age for approval

3 moinitial approval duration (TRD)

1 moinitial approval duration (MDD w/ SI/behavior)

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Coverage Criteria for Spravato (esketamine)

Initial Therapy - Treatment Resistant Depression

Covered when ALL of the following are met for Treatment-Resistant Depression (TRD):

TRD Initial Authorization: 1. Diagnosis of treatment resistant depression; 2. Member is ≥18 years of age; 3. Prescriber is a specialist (i.e., psychiatrist including psychiatric nurse practitioners or physician assistants) or consult notes from a specialist dated within 1 year are provided; 4. Medical records documenting an inadequate response (defined as ≥4 weeks of therapy) or adverse reaction to ONE SSRI and ONE other non-SSRI antidepressant; 5. Medical records documenting an inadequate response (defined as concomitant use of an augmenting agent plus antidepressant therapy combined ≥4 weeks of therapy) or adverse reaction with ONE or contraindication to ALL of the following antidepressant augmentation strategies: a. Second-generation antipsychotic (Aripiprazole, olanzapine, quetiapine extended-release, and Rexulti [brexpiprazole]); b. Lithium; c. A second antidepressant from a different class; d. Thyroid hormone; 6. Requested agent will be used in combination with an oral antidepressant; 7. Appropriate dosing.

Do not flatten AND/OR logic; the policy requires either inadequate response to augmentation strategies as defined or adverse reaction/contraindication to all listed augmentations.

Initial Therapy - MDD with Acute Suicidal Ideation/Behavior

Covered when ALL of the following are met for Depressive symptoms in adults with MDD with acute suicidal ideation or behavior:

MDD with Acute Suicidal Ideation/Behavior Initial Authorization: 1. Diagnosis of MDD with acute suicidal ideation or behavior; 2. Member is ≥18 years of age; 3. Prescriber is a specialist (i.e., psychiatrist including psychiatric nurse practitioners or physician assistants) or consult notes from a specialist dated within 1 year are provided; 4. ONE of the following: a. Medical records documenting current acute suicidal ideation or behavior related to depressive symptoms of MDD; b. Member was stabilized on esketamine during a psychiatric hospitalization; 5. Requested agent will be used in combination with an oral antidepressant (requests indicating combination with quetiapine can be approved if all other criteria are met); 6. Appropriate dosing.

For this indication, initial approval durations differ and reauthorization beyond 1 month should meet initial TRD criteria.

Continuation/Reauthorization

Continuation and reauthorization criteria:

Continuation for TRD: Reauthorization by physician will infer a positive response to therapy; reauthorizations will be granted for up to 1 year for treatment resistant depression.

Continuing therapy requires physician reauthorization and evidence of benefit.

Continuation for MDD with Suicidal Ideation/Behavior: For depressive symptoms in adults with MDD with acute suicidal ideation or behavior, continuation follows initial criteria; requests for recertification beyond 1 month should meet initial TRD criteria.

Initial approval for this indication is 1 month; recertification beyond 1 month must meet TRD initial criteria.

There are no specialty limitations for Spravato under the MassHealth medical benefit. Spravato is also available through the pharmacy benefit; providers should consult the MassHealth Drug List for pharmacy benefit coverage and any pharmacy-specific criteria.

Use is not authorized if the member does not meet the clinical criteria set forth in this policy. Prior authorization will be granted only when all required documentation is submitted demonstrating that the member meets the specified criteria.

For Treatment-Resistant Depression (TRD) the documentation must include: evidence of diagnosis, age ≥18, specialist prescriber or consult notes (within 1 year), and medical records showing an inadequate response (defined as ≥ 4 weeks of therapy) or an adverse reaction to one SSRI and one non-SSRI antidepressant. The record must also document either inadequate response (defined as concomitant use of an augmenting agent plus antidepressant therapy combined for ≥ 4 weeks) or an adverse reaction/contraindication to all listed augmentation strategies (second-generation antipsychotic such as aripiprazole, olanzapine, quetiapine XR, or brexpiprazole; lithium; a second antidepressant from a different class; thyroid hormone).

Authorization will be denied if required documentation is not submitted or criteria are not met, including failure to document the required prior antidepressant trials, lack of specialist involvement or consult notes, or if Spravato will not be used in combination with an oral antidepressant as required.

Provider Actions and Documentation Requirements

Prior Authorization

Prior Authorization Required

Prior authorization required under the medical benefit for Spravato for MassHealth members; authorization granted when all specified clinical criteria are met.

Medical Benefit: prior authorization required
Authorization granted when documentation demonstrating all clinical criteria is submitted

Step Therapy

Program Type

No step therapy requirement is listed; program type is Prior Authorization only.

Program type: Prior Authorization
No step therapy requirement listed

Administration Setting and Level of Care

Outpatient/Medical infusion or supervised administration

Level-of-care criteria for outpatient/medically supervised administration:

Admission for Spravato administration: Member meets diagnosis-specific criteria (TRD or MDD with acute suicidal ideation/behavior), is ≥18 years old, and has specialist prescriber or consult documentation; for suicidal ideation/behavior, documentation of current acute suicidal ideation/behavior or stabilization on esketamine during psychiatric hospitalization is required.

Applies to clinic/hospital settings administering Spravato under the medical benefit.

Continued stay/administration: Reauthorization infers positive clinical response; duration limits apply (TRD: initial 3 months, reauthorization up to 1 year; MDD with acute suicidal ideation/behavior: initial 1 month; recertification beyond 1 month should meet TRD criteria).

Treating clinician must reauthorize; documentation of benefit implied by reauthorization.

Treatment Modalities

Intranasal esketamine (Spravato)

Specific modality criteria for intranasal esketamine (Spravato):

Spravato use: Spravato (esketamine) must be used in conjunction with an oral antidepressant per indication; appropriate dosing must be documented.

Policy allows combination with quetiapine if other criteria are met for the suicidal ideation/behavior indication.

Key Definitions

Treatment-resistant depression (TRD) — definition as used in this policy

Policy definitionDepression in adults with inadequate response to prior antidepressant therapy as specified in the coverage criteria (i.e., documented inadequate response or adverse reaction to one SSRI and one non-SSRI antidepressant, with additional requirements regarding augmentation strategies).

Minimum ageAdults aged ≥18 years.

Required prior trialsMedical records must document inadequate response (≥4 weeks of therapy) or adverse reaction to ONE SSRI and ONE other non-SSRI antidepressant.

Augmentation requirementEither inadequate response (≥4 weeks) while on an antidepressant plus an augmenting agent, or adverse reaction/contraindication to all listed augmentation strategies (second‑generation antipsychotic such as aripiprazole, olanzapine, quetiapine XR, brexpiprazole; lithium; a second antidepressant from a different class; thyroid hormone).

Use with oral antidepressantRequested esketamine must be used in combination with an oral antidepressant per the policy.

Background

Spravato (esketamine) is indicated for use in conjunction with an oral antidepressant for: 1) treatment-resistant depression (TRD) in adults and 2) depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior. The policy covers Spravato when administered in-clinic under the medical benefit; pharmacy availability is noted on the MassHealth Drug List.

Per the plan summary, Spravato is provided under a Prior Authorization program and is covered under the medical benefit for MassHealth members. Contact information for medical benefit prior authorization is provided in the policy header.