CurrentMass General Brigham Health PlanPolicy N/A

Spravato (esketamine) — Major Depressive Disorder / Treatment-Resistant Depression (medical-benefit prior authorization)

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This medical-benefit prior authorization policy governs coverage and clinical criteria for Spravato (esketamine) for adults with treatment-resistant depression or MDD with acute suicidal ideation/behavior for Mass General Brigham Health Plan (including MassHealth UPPL). It applies to providers requesting authorization under the plan's medical benefit.

Policy Summary

PayerMass General Brigham Health Plan

PolicySpravato (esketamine) — MDD / TRD (medical-benefit prior authorization)

Policy CodePolicy N/A

Change TypeCriteria revision (dosing, augmentation, documentation, reauth limits)

Effective DateJul 1, 2026

Last ReviewAug 13, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with specialist prescriber or specialist consult, documentation of failed trials (one SSRI + one non-SSRI), augmentation trial details, and a current validated depression rating.

SourceLink

POLICY UPDATE CHANGES

Step-through trial of a mood stabilizer was clarified to ONE of: carbamazepine, divalproex/valproate/valproic acid, lamotrigine, or lithium.

Medical records will be required documenting a current assessment using a validated depression rating scale (e.g., MADRS, HAM-D, PHQ-9, BDI).

Approval durations for renewals were clarified and Spravato dosed twice weekly was updated to a maximum of 6 months.

Dosing schedules and maintenance phase frequency were further specified (induction, maintenance weeks 5-8, weeks 9+, >12 months).

≥18

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CurrentMass General Brigham Health PlanPolicy N/A

Spravato (esketamine) — Major Depressive Disorder / Treatment-Resistant Depression (medical-benefit prior authorization)

Customize your policy alerts

Sign up for all Mass General Brigham Health Plan policy alerts

Know when Mass General Brigham Health Plan releases new policies or updates existing guidance.

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Policy Summary

PayerMass General Brigham Health Plan

PolicySpravato (esketamine) — MDD / TRD (medical-benefit prior authorization)

Policy CodePolicy N/A

Change TypeCriteria revision (dosing, augmentation, documentation, reauth limits)

Effective DateJul 1, 2026

Last ReviewAug 13, 2025

Next Review DateN/A

SourceLink

POLICY UPDATE CHANGES

Step-through trial of a mood stabilizer was clarified to ONE of: carbamazepine, divalproex/valproate/valproic acid, lamotrigine, or lithium.

Medical records will be required documenting a current assessment using a validated depression rating scale (e.g., MADRS, HAM-D, PHQ-9, BDI).

Approval durations for renewals were clarified and Spravato dosed twice weekly was updated to a maximum of 6 months.

Dosing schedules and maintenance phase frequency were further specified (induction, maintenance weeks 5-8, weeks 9+, >12 months).

≥18

Minimum age for eligible members

1 monthInitial authorization duration

6 monthsMax reauth for twice-weekly maintenance

≥2Required prior failed monotherapies

Validated scaleObjective assessment required

Spravato Authorization Criteria

Authorization will be granted when ALL of the following are met; documentation specified must be submitted with the request.

ALL of the following

Diagnosis of major depressive disorder (MDD) OR treatment-resistant depression (TRD) or MDD with acute suicidal ideation/behavior
Age: >=18 years of age
Minimum age for eligible members
Prescriber qualifications: Prescriber is a specialist (psychiatrist, including psychiatric NP/PA) OR consult notes from a specialist dated within 1 year are provided
Specialist prescriber or specialist consult required
Prior monotherapy trials: Medical records documenting inadequate response to monotherapy (>=4 weeks each) or adverse reaction to BOTH: (a) ONE SSRI AND (b) ONE other non-SSRI antidepressant>=4 weeks each
Document trials and outcomes
Augmentation strategies: Medical records documenting inadequate response, adverse reaction to ONE, or contraindication to ALL of the following augmentation strategies (augmentation defined as >=4 weeks overlap of an SSRI or SNRI with the augmentation agent after two failed monotherapy trials): (a) second-generation antipsychotic (examples: aripiprazole, olanzapine, quetiapine XR, brexpiprazole), (b) ONE mood stabilizer (carbamazepine OR divalproex/valproate/valproic acid OR lamotrigine OR lithium), (c) a second antidepressant from a different class, OR (d) thyroid hormone>=4 weeks overlap when applicable
Names of example agents must be documented in chart
Objective depression assessment: Medical records documenting a current depression assessment using a validated scale (e.g., MADRS, HAM-D, PHQ-9, BDI)current at time of request
Include numeric score in documentation
Dosing consistency: Requested dosing is consistent with policy dosing guidance (see dosing node): induction and maintenance regimens documented
Specify induction vs maintenance phase dosing in request

Coding and Initial Authorization

No specific codes listedmixed

No codes listed

Initial authorization duration

Initial approval1 month

SourceLimitations: Initial approvals will be granted for 1 month (see policy).

Applies toSpravato administration under the medical benefit

Prior Authorization & Documentation Requirements

Prior Authorization

Prior authorization required (medical benefit)

Prior authorization is required under the medical benefit for Spravato (esketamine). Requests must include the documentation specified in the criteria (diagnosis, age, specialist prescriber or specialist consult, prior treatment history, validated depression rating scale, and dosing). Authorization may be reviewed on a case‑by‑case basis for members who are new to the plan and are currently receiving the requested medication.

Requests must include diagnosis, age (≥18), prescriber specialty or specialist consult dated within 1 year, prior treatment history, depression rating scale, and dosing

Documentation Required

Specialist prescriber or recent specialist consult required

The prescriber must be a specialist (psychiatrist, including psychiatric nurse practitioner or physician assistant). If the prescriber is not a specialist, provide consult notes from a specialist dated within 1 year.

Key Definitions

Treatment‑resistant depression (TRD)

DefinitionTreatment-resistant depression (TRD) is defined as inadequate response to monotherapy trials (≥4 weeks each) including at least one SSRI and one non-SSRI antidepressant, plus inadequate response or intolerance/contraindication to specified augmentation strategies.

Minimum trials - monotherapyInadequate response to ≥4 weeks each of one SSRI and one non-SSRI antidepressant.

Augmentation requirementAfter two failed monotherapy trials, inadequate response to augmentation strategies is required (see Augmentation definition).

Augmentation (required elements)

DefinitionAugmentation = overlap of an SSRI or SNRI with one of the listed agents for ≥4 weeks following two failed monotherapy trials.

Acceptable augmentation agents — antipsychotic examples

Outpatient Medical Administration & Maintenance Treatment

Outpatient medical administration (esketamine) / maintenance treatment

Outpatient medical administration and maintenance treatment covered when ALL of the following location and clinical criteria are met.

ALL of the following

Location/setting: Service is provided in an outpatient medical administration setting appropriate for supervised intranasal esketamine administration (medical benefit)
Must meet site standards for monitoring and post-dose observation
Authorization prerequisites: Member meets authorization criteria for Spravato (diagnosis, age, prescriber qualifications, prior treatment history, and validated depression assessment) as documented in the chart
See Spravato Authorization Criteria
Maintenance dosing rules:

Intranasal Esketamine (Spravato) Specifics

Intranasal esketamine (Spravato)

ALL of the following

Indication (ONE of)
- TRD: Treatment-resistant depression (TRD) in adults (adjunctive to an oral antidepressant)
  TRD defined by inadequate response to listed monotherapy and augmentation trials
- MDD with acute suicidal ideation/behavior: Major depressive disorder (MDD) with acute suicidal ideation or behavior in adults (used in combination with an oral antidepressant); documentation dated within 4 weeks required OR stabilization on esketamine during psychiatric hospitalization within 4 weeks
  See acute suicidal documentation requirements
Induction and maintenance dosing (ALL of)

Authorization Durations and Reauthorization Intervals

Spravato administration (medical benefit) — initial authorization

Initial approval1 month

ServiceSpravato administration (medical benefit)

NoteInitial approvals will be granted for 1 month per policy limitations.

Spravato administration — reauthorization intervals

Reauthorization intervals (general)Reauthorizations vary by maintenance dosing and stability: intervals range from 1 month up to 12 months depending on dose and duration.

Maintenance weeks 5–856 mg or 84 mg once weekly: reauthorization = 1 month; twice weekly (if attempts to reduce destabilized): reauthorization = 1 month.

Policy Summary

PayerMass General Brigham Health Plan

PolicySpravato (esketamine) — MDD / TRD (medical-benefit prior authorization)

Policy CodePolicy N/A

Change TypeCriteria revision (dosing, augmentation, documentation, reauth limits)

Effective DateJul 1, 2026

Last ReviewAug 13, 2025

Next Review DateN/A

SourceLink

On This Page

Acceptable prescribers: psychiatrist or psychiatric NP/PA

Specialist consult notes must be dated within 1 year

Documentation Required

Required clinical documentation: prior trials, augmentation, and validated rating

Medical records must document prior medication trials and objective severity at the time of request: an inadequate response or adverse reaction to at least ONE SSRI and ONE non‑SSRI antidepressant, documentation of inadequate response/adverse reaction or contraindication to the listed augmentation strategies, and a current assessment using a validated depression rating scale (e.g., MADRS, HAM‑D, PHQ‑9, BDI).

Document inadequate response (≥4 weeks each) to one SSRI and one non‑SSRI antidepressant
Document inadequate response, adverse reaction, or contraindication to ONE augmentation strategy from: a second‑generation antipsychotic (examples listed) AND ONE mood stabilizer (carbamazepine; divalproex/valproate/valproic acid; lamotrigine; or lithium) OR a second antidepressant from a different class OR thyroid hormone
Provide a current validated depression rating scale score (e.g., MADRS, HAM‑D, PHQ‑9, BDI)

Billing Rule

Benefit routing — medical benefit; pharmacy availability on MassHealth Drug List

Spravato is covered under the medical benefit but is also available through the pharmacy benefit; providers should consult the MassHealth Drug List for pharmacy coverage and specific pharmacy criteria.

Pharmacy benefit availability and criteria are listed on the MassHealth Drug List

Second‑generation antipsychotic examples: aripiprazole, olanzapine, quetiapine XR, brexpiprazole (Rexulti).

Acceptable augmentation agents — mood stabilizersONE of: carbamazepine; divalproex/valproate/valproic acid; lamotrigine; or lithium.

Other augmentation optionsA second antidepressant from a different class OR thyroid hormone may be used as augmentation per criteria.

Maintenance treatment follows policy dosing rules: weeks 5-8 dosing frequency (once weekly OR twice weekly if attempts to reduce destabilized the patient); weeks 9+ dosing frequency (once weekly or every other week for up to 12 months OR twice weekly if destabilized on lower frequency); beyond 12 months dosing <= once weekly or twice weekly only if attempts to decrease destabilized the patient

Reauthorization intervals tied to maintenance dosing; twice-weekly maintenance approvals limited per policy

Continuation criteria: Continuation/reauthorization documentation includes evidence of positive clinical response and current depression score no greater than the score on prior submission

Objective monitoring required for reauthorization

Induction dosing: Induction phase (weeks 1-4): 56 mg OR 84 mg twice weekly

Document induction schedule

Maintenance 5-8 dosing: Maintenance phase (weeks 5-8): 56 mg OR 84 mg once weekly OR twice weekly if attempts to decrease to once weekly resulted in destabilization

Attempts to reduce frequency must be documented if twice weekly continued

Maintenance 9+ dosing: Maintenance phase (weeks 9+): 56 mg OR 84 mg once weekly OR every other week for up to 12 months OR twice weekly if attempts to decrease to once weekly resulted in destabilizationup to 12 months

Reauthorization intervals vary by dosing and stability

Beyond 12 months dosing: Maintenance phase (>12 months): 56 mg OR 84 mg <= once weekly OR twice weekly only if attempts to decrease to once weekly resulted in destabilization

Long-term dosing must document failed attempts to reduce frequency

Exclusion / other treatment-specific rules (ALL of)

Acute suicidal documentation: For MDD with acute suicidal ideation/behavior: medical records within the last 4 weeks documenting current acute suicidal ideation/behavior related to depressive symptoms OR documentation of stabilization on esketamine during psychiatric hospitalization within the last 4 weekswithin 4 weeks
Required for this indication
Combination therapy requirement: Requested agent for acute suicidal indication will be used in combination with an oral antidepressant (requests indicating combination with quetiapine may be approved if all other criteria met)
Quetiapine combination permitted if criteria otherwise met
Required documentation: Prescriber, prior treatment, augmentation, and validated depression assessment documentation must be provided per authorization criteria
Include specialist consults, prior trials, and current depression scale score

Maintenance weeks 9+56 mg or 84 mg once weekly or every other week: reauthorization = 1 month; twice weekly (if destabilization on dose reduction): reauthorization = 6 months (max for twice‑weekly).

Maintenance >12 months56 mg or 84 mg ≤ once weekly: reauthorization = 12 months; twice weekly with destabilization on dose reduction: reauthorization = 6 months.