ModifiedPremera BluecrossPolicy 5.01.609

Spravato (esketamine) Nasal Spray coverage

This policy defines medical necessity, coverage criteria, dosing limits, documentation, coding, and investigational uses for Spravato (esketamine) nasal spray for treatment of depression for providers and benefit managers.

Policy Summary

PayerPremera Bluecross

PolicySpravato (esketamine) Nasal Spray coverage

Policy CodePolicy 5.01.609

Change TypeMaterial revisions and clarifications (dose limits, monotherapy, trial counting)

Effective Date

Next Review Date

Key ActionSubmit prior authorization with documentation of DSM-5 MDD diagnosis, prior antidepressant failures, induction and maintenance dosing, and 2‑hour REMS monitoring adherence.

SourceLink

POLICY UPDATE CHANGES

Removed separate coverage criteria for MDD with acute suicidal ideation or behavior and applied MDD criteria regardless of presence of acute suicidal ideation or behavior.

Clarified that maintenance dose (week 5 and after) is limited to 84 mg once weekly for the first 12 months and for reauthorization the same limit applies for the next 12 months.

Removed requirement that Spravato must be used in conjunction with an oral antidepressant (monotherapy allowed) consistent with FDA approval.

Removed the stipulation that adding a second antidepressant to a trial counted as an augmenting agent rather than a separate antidepressant trial.

Clarified documentation requirements should include induction dose and maintenance dose frequency and time period specified.

Up to 12 monthsinitial approval length

84 mgmax maintenance dose (weekly)

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84 mg twice/wk ≤8wtemporary increased frequency

Jan 21, 2025FDA monotherapy approval

G2082,G2083,J0013,S0013HCPCS codes referenced

Coverage Criteria

Initiation and Re-authorization criteria (historical clarifications)

Initiation and Re-authorization criteria (historical clarifications):

{

"operator":"all",

"children":[

{"text":"For initial authorization (first course or a repeat course), Spravato (esketamine) may be approved up to 12 months for the treatment of depression. If Spravato was started under a non-Company plan, medical necessity criteria must have been met at the time when Spravato was started.", "note":"05/01/23, 04/01/25, 06/01/25 history entries"},

{"text":"Re-authorization for Spravato for the treatment of depression may be approved up to 12 months in duration when clinical benefit/response at the time of re-authorization shows chart notes documenting improvement in signs and symptoms of major depressive disorder as demonstrated by documentation of individual's symptoms and their severity or by one or more standardized depression rating scales.", "note":"08/01/25, 12/01/25 history entries"},

{"text":"At re-authorization, there must be no new or past or previously undisclosed diagnosis of a bipolar disorder and no new or past or previously undisclosed manic or hypomanic episodes.", "note":"03/01/26 history entry"},

{"text":"At re-authorization, there must be no current psychosis.", "note":"03/01/26 history entry"},

{"text":"At re-authorization, there must be no current substance use disorder unless in remission (complete abstinence for at least three months) or complete abstinence for at least one month and the individual agrees to continue to remain abstinent; alternatively, the individual may be confined 24/7 in a hospital or residential treatment facility or similar facility where access to alcohol or non-prescribed drugs is not possible and the individual has agreed to not use alcohol or non-prescribed drugs after discharge while continuing treatment with Spravato.", "note":"06/01/25, 05/01/23, 06/01/25 history entries"},

{"text":"No concurrent use of any hallucinogens/psychedelics, illicit drugs, illicit or non-prescribed stimulants, or prescribed stimulants in excess of prescribed doses; no concurrent use of any prescribed controlled medications that were not prescribed for the individual. If the individual uses alcohol or marijuana, the individual agrees to either cease use while being treated with Spravato or to not use within 24 hours before and 24 hours after each Spravato treatment.", "note":"03/01/25, 04/01/25, 06/01/25, 05/01/23 history entries"},

{"text":"Maintenance dose prescribed (week 5 and after) is limited to 84 mg once weekly for the rest of the first 12 months of treatment; for re-authorization the maintenance dose prescribed is limited to 84 mg once weekly for the next 12 months of treatment.", "note":"2025 Update; 12/01/25 history entries"},

{"text":"Documentation requirements for failed medication trials: each medication that failed must be individually identified, and the reason or reasons for failure must be specified either for each medication individually or collectively for all of the medications that failed. Records should include documentation of at least 30 continuous days with no or inadequate improvement for each failed trial unless stopped sooner because of intolerable adverse effects.", "note":"05/01/23; 08/01/25; 03/01/25 history entries"},

Clarifications: the policy removed the stipulation that addition of a second antidepressant to an antidepressant trial is considered an augmenting agent rather than a separate antidepressant trial (08/01/24). The requirement that an oral antidepressant be used in conjunction with Spravato was removed to be consistent with the FDA's January 21, 2025 approval of Spravato as monotherapy for Major Depressive Disorder (03/01/25). The policy clarifies that members continuing use of Spravato must meet medical necessity criteria and that Spravato in formulations other than the nasal spray is investigational.

08/01/24; 03/01/25; 10/01/24 history entries

"label":"Initiation and Re-authorization Criteria Clarifications",

"operator":"all"

}

Coding

HCPCS / J-codesHCPCS

G2082	Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post administration observation.
G2083	Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified health care professional and provision of greater than 56 mg esketamine nasal self-administration, includes 2 hours post administration observation.
J0013	Esketamine, nasal spray (Spravato), 1 mg (new code effective 01/01/26).
S0013	Esketamine, nasal spray (Spravato), 1 mg (code termed effective 01/01/26).

Historical and current HCPCS coding referencedHCPCS

G2082	HCPCS code added previously (historical coding update)
G2083	HCPCS code added previously (historical coding update)
S0013	HCPCS code (termed effective Jan 1, 2026)
J0013	New HCPCS code added effective Jan 1, 2026

HCPCS Code UpdatesHCPCS

J0013	New HCPCS code added (esketamine-related code as indicated in history)
S0013	Previously used HCPCS code; indicated as termed effective January 1, 2026

Depression severity scales (example cutoffs)

MADRS (Montgomery–Åsberg Depression Rating Scale)Score range 0–60; 0–6 none, 7–19 mild, 20–34 moderate, 35–60 severe

HAM-D (Hamilton Rating Scale for Depression) — 17 itemScore range 0–52; 0–7 none, 8–16 mild, 17–23 moderate, ≥24 severe

Use in policy clinical assessmentStandardized depression rating scales (e.g., MADRS, HAM-D) may be used to document worsening or improvement for dosing decisions and re-authorization

Maintenance dose limit — week 5 and after

Maintenance dose limit (weeks 5+)84 mg once weekly for the remainder of the first 12 months of treatment

Applies to initial authorization

Provider Actions & Documentation

Prior Authorization

Prior Authorization Required

Prior authorization required. Initial authorization and re-authorization may be approved for up to 12 months when all medical necessity criteria are met. For re-authorization, clinical benefit/response must be documented in the chart (improvement in signs/symptoms or standardized rating scale) and no new or previously undisclosed bipolar disorder, manic/hypomanic episodes, or current psychosis must be present.

Initial and re-authorization approval period: up to 12 months.
Re-authorization requires documentation of maintained clinical benefit/response.

Prior Authorization

Prior Authorization and Re-authorization Requirements

Re-authorization requires continued use of Spravato consistent with policy criteria and documentation showing ongoing benefit. Records must show maintenance dosing frequency and time period consistent with a 12‑month authorization and that criteria (including substance use/abstinence rules and absence of contraindications) remain met.

Re-authorization: chart notes documenting improvement and maintenance of response.

Definitions

Depression is common and a substantial minority of individuals do not adequately respond to antidepressant monotherapy. In clinical trials of esketamine for treatment-resistant depression (TRD), TRD was defined as major depressive disorder that failed to respond to ≥2 different antidepressants for the current episode. Esketamine has been evaluated in multiple Phase 3 programs (TRANSFORM and SUSTAIN trials) demonstrating rapid symptom reduction in some studies and longer-term relapse-delay in maintenance trials, supporting its use in select adults with TRD.

Treatment‑resistant depression (TRD) — trial‑based definition

TRD trial-based definitionIn Spravato clinical trials, treatment‑resistant depression (TRD) was defined as major depressive disorder failing to respond to ≥2 different antidepressants for the current episode

Context of trialsEsketamine was studied as adjunct to a newly initiated oral antidepressant in TRANSFORM trials and in long-term SUSTAIN studies

Implication for coveragePolicy applies trial-based TRD definition when assessing eligibility (failed ≥2 antidepressants for current episode) as described in trials

Failed medication trial — definition

Initial Therapy Criteria

inv-50: Initial therapy — criteria and dosing limits

Initial therapy criteria and dosing limits

Age and diagnosis: Age ≥18 and DSM-5 major depressive disorder without psychotic features (unipolar)

Prior treatments: Failed 3 antidepressants from at least 2 different classes OR failed 2 antidepressants from 2 different classes plus an augmenting agent (failed trial defined in policy)

Each failed medication should be identified with reasons and duration documented

Induction dosing: Induction options include 84 mg twice weekly for weeks 1–4 or 56 mg on day 1 followed by up to 84 mg twice weekly for 4 weeks per prescribing information

Specific dosing algorithms are per FDA prescribing information

Continuation / Maintenance Criteria

inv-54: Continuation / Maintenance therapy — Re-authorization and continuation requirements

Re-authorization/Continuation therapy requirements

Clinical benefit: Chart notes must document improvement in signs and symptoms of MDD as demonstrated by documentation of individual's symptoms and their severity or by one or more standardized rating scales, and improvement is being maintained

Improvement may be documented by clinician notes or standardized scales

Safety and diagnoses: No new or previously undisclosed bipolar disorder or manic/hypomanic episodes; no current psychosis; substance use criteria per policy must be met

Maintenance dosing: Maintenance dose limited to 84 mg once weekly for the next 12 months if re-authorization criteria are met84 mg once weekly

Step Therapy

Requirement	Details
Tried and failed 3 antidepressants from at least 2 different classes OR tried and failed 2 antidepressants from 2 different classes plus an augmenting agent (see policy for augmenting agent definition).
Each failed medication trial must be documented; a failed trial requires at least 30 continuous days at antidepressant dose unless stopped earlier for intolerable adverse effects. Insomnia-dose antidepressants count only if given at full antidepressant doses (e.g., amitriptyline ≥150 mg).

Coverage Label	Policy statement
Use with neuromodulation modalities (TMS/ECT/VNS)
Policy states use of Spravato in conjunction with neuromodulation modalities (TMS, ECT, VNS) is investigational and not an accepted adjunct or step prior to coverage.

Requirement	Details
Documentation of prior antidepressant treatment history is required; counting of trials revised so that addition of a second antidepressant to a trial is no longer automatically considered only an augmenting agent. Policy requires failed trials as specified above (see step therapy).
For prior trials, the reason(s) for failure must be specified either for each medication or collectively; documentation should include at least 30 continuous days on each failed trial unless stopped for intolerable adverse effects.

Requirement	Documentation required
Authorization requires that prior medication failures be documented; each failed medication should be identified or collective reasons provided as allowed by policy.
Medical record must document DSM-5 diagnosis, medication history, induction and maintenance dosing and frequencies, and specify duration (≥30 continuous days) or intolerability reason for each failed trial.

Quantity Limits

Spravato dosing (84 mg twice per week) — quantity limit reference

Induction/initial quantity limitationInduction dosing limited to 84 mg twice per week (or 56 mg on day 1 followed by up to 84 mg twice weekly) as per induction period

Temporary maintenance increaseDuring maintenance, frequency may be increased temporarily to 84 mg twice weekly when criteria for worsening are met (limited duration per policy)

Policy quantity contextPolicy quantity limits reference 84 mg dosing for both induction and permitted temporary maintenance increases

Spravato dosing numeric limit reference

Numeric dosing limit84 mg (dose unit) is the maximum maintenance dose (once weekly) during weeks 5–52 and the induction twice‑weekly dosing limit

Frequency limits

Site of Care Requirements

Note

Supervised administration and benefit management

Esketamine must be administered under the direct supervision of a healthcare provider with post‑administration observation; Spravato is managed through pharmacy and medical benefits.

Treatment session includes nasal administration and supervised post‑administration observation

Documentation Required

Observation period and driving restrictions

Patients must be monitored for at least 2 hours after each Spravato treatment session and be assessed for clinical stability before discharge; driving restrictions apply post‑administration and should be documented.

Monitor at least 2 hours post‑dose and document readiness for discharge
Document counseling regarding driving restrictions after administration

Policy Summary

PayerPremera Bluecross

PolicySpravato (esketamine) Nasal Spray coverage

Policy CodePolicy 5.01.609

Change TypeMaterial revisions and clarifications (dose limits, monotherapy, trial counting)

Effective Date

Next Review Date

Key ActionSubmit prior authorization with documentation of DSM-5 MDD diagnosis, prior antidepressant failures, induction and maintenance dosing, and 2‑hour REMS monitoring adherence.

SourceLink

On This Page

Limit specified for maintenance dosing after induction (week 5 onward) during the first 12-month authorization period

Applies to documentationMedical record must document maintenance dosing frequency and time period consistent with 12‑month authorization

Maintenance dose limit (restated)

Maintenance dose definitionThe esketamine dose prescribed from week 5 onward; limited to 84 mg once weekly for the remainder of the first 12 months of treatment

Re-authorizationFor re-authorization, maintenance dose is limited to 84 mg once weekly for the next 12 months if continuation criteria are met

Temporary increase allowedPolicy allows temporary increase to twice weekly when criteria for worsening are met, but must return to 84 mg once weekly thereafter

Documentation must confirm no new bipolar diagnosis, no current psychosis, and substance use criteria met.

Prior Authorization

Authorization Periods

Authorization periods: initial authorization (first course or repeat course) and any re-authorization may be approved for up to 12 months. Non-formulary or formulary status does not change the 12‑month authorization period.

Initial authorization period: up to 12 months.
Re-authorization period: up to 12 months.

Documentation Required

Prior Authorization Requirements — Dosing & Documentation

Prior authorization requests must document dosing details, prior medication trials, and rationale for failures. Induction and maintenance dosing (frequency and time period) must be specified in the record. Maintenance dosing after week 4 is limited per policy (84 mg once weekly for week 5+ during the first 12 months).

Induction dosing limits: up to 84 mg twice weekly (or option: 56 mg day 1 then up to 84 mg twice weekly for first 4 weeks).
Maintenance dosing limit: 84 mg once weekly for week 5+ during first 12 months.
Documentation must include induction dose and maintenance dose frequency and time period.

Denial Risk

Investigational Indications — Denial Triggers

Uses of Spravato that are not described in the Medical Necessity criteria are investigational and should be denied. Examples include treatment for chronic pain, bipolar depression, use with other ketamine formulations or psychedelic drugs, and use in conjunction with neuromodulation modalities (TMS, ECT, VNS). Use that fails the age or diagnosis requirements is investigational.

Investigational indications include chronic pain, bipolar depression, other ketamine formulations, concomitant psychedelic drugs.
Use with neuromodulation (TMS, ECT, VNS) is investigational.

Prior Authorization

Use Meeting Age and Diagnosis Requirements

Use of Spravato that meets the age (18+) and DSM-5 diagnosis requirements for major depressive disorder without psychotic features (unipolar) may be considered medically necessary when all other policy criteria are met and properly documented.

Member must be 18 years or older and meet DSM-5 criteria for MDD without psychotic features (unipolar, not bipolar).
If criteria are met and documented, Spravato use may be approved up to the authorization period limits.

Documentation Required

Contraindications and REMS

Contraindications must be checked and documented. Absolute contraindications include aneurysmal vascular disease, arteriovenous malformation, history of intracerebral hemorrhage, and hypersensitivity to esketamine, ketamine, or excipients. REMS program requirements (monitoring for 2 hours post-treatment) must also be followed.

Contraindications: aneurysmal vascular disease, arteriovenous malformation, prior intracerebral hemorrhage, hypersensitivity to esketamine/ketamine/excipients.
REMS: administer in healthcare setting and monitor individuals for 2 hours after each treatment session.

Denial Risk

Denial Triggers for Unmet Criteria

Requests that do not meet policy criteria should be denied as not medically necessary; documentation must support any appeal. Failure to document required elements (diagnosis, prior trials, dosing details, reasons for medication failures) is a common denial trigger.

Each failed medication trial must be individually identified with the reason(s) for failure, and documentation of at least 30 continuous days on the medication unless stopped for intolerable adverse effects.
Records must include office visit notes with diagnosis, history, exam, and medication history.

Billing Rule

Billing and Coding — Update Codes

Providers must use the correct, up‑to‑date HCPCS/CPT codes when submitting claims. Coding updates have added HCPCS J0013 and termed S0013 effective January 1, 2026; failure to update codes may result in claim denials.

Coding update: J0013 added; S0013 termed (effective 01/01/2026).
Confirm coding against current policy history and payer guidance before claim submission.

Note

Medicare Advantage Exclusion

This medical policy does not apply to Medicare Advantage members. Providers should consult the member benefit booklet or contact member services for Medicare Advantage coverage rules; submitting claims under this policy for Medicare Advantage members may trigger denial.

Policy scope excludes Medicare Advantage.
Verify member plan type prior to authorization/claim submission.

Documentation Required

Maintenance Dosing Documentation Requirements

For maintenance dosing documentation, records must specify the maintenance dose frequency and the time period consistent with a 12‑month authorization. The maintenance dose limit for week 5 and after is 84 mg once weekly for the first 12 months; re-authorization must reflect the same maintenance dosing limits for the next 12 months.

Documentation must state week-by-week dosing during induction and the maintenance plan (frequency and duration).
Maintenance dosing limit: 84 mg once weekly for week 5+ during the first 12 months; same limit applies for re-authorization period.

Documentation Required

Prior Medication Trials — Documentation Required

Prior medication trials must be clearly documented. The policy requires failed trials of antidepressants: either 3 antidepressants from at least 2 classes, or 2 from different classes plus an augmenting agent (per historical criteria), with each failed medication identified and the reason(s) for failure specified (or stated collectively). A failed trial requires at least 30 continuous days of use unless stopped for intolerable adverse effects.

Failed trial definition: not effective, partially/inadequately effective, loss of effectiveness, or intolerable side effects.
Documentation: at least 30 continuous days for each failed trial unless discontinued sooner due to adverse effects; specify medication names and reasons for failure.

Note

Policy History & Documentation Requirements

Policy history and revisions require that documentation include induction dose and maintenance dose frequency and time period specified; ensure records reflect any policy changes noted in the history (e.g., dosing limits, trial counting rules, coding updates) when submitting prior authorization requests.

Follow current policy statements and note relevant effective dates when relying on prior authorizations from non‑Company plans.
Ensure documentation reflects the policy's current dosing limits and prior trial requirements.

Definition of failed medication trialA failed trial is: not effective, partially but inadequately effective, initially effective but then lost effectiveness, or stopped for intolerable side effects

Minimum duration documentedEach failed medication trial should include documentation of at least 30 continuous days unless stopped earlier for intolerable adverse effects

Dose considerationsAntidepressants commonly used for insomnia count only if given at minimum antidepressant doses per policy examples

TRD — trial definition from clinical trials

Clinical‑trial TRD definitionTRD defined in trials as major depressive disorder with failure to respond to ≥2 different antidepressants for the current episode

Trial role in evidenceThis trial definition underpins eligibility and was used in TRANSFORM and SUSTAIN programs evaluating esketamine

Coverage correspondencePolicy aligns coverage with the trial definition to identify individuals meeting TRD criteria

REMS — required risk evaluation and mitigation strategy

REMS requirementEsketamine is available through a REMS program due to risks of sedation, dissociation, abuse/misuse, and increased suicidal thoughts/behavior

Administration and monitoringREMS mandates administration by a health care professional with monitoring for 2 hours after each treatment session

Clinical assessment before dischargeIndividuals must be assessed for clinical stability before departure from the treatment setting per REMS

Maintenance dose definition — week 5+

Maintenance dose (week 5+) limitWeek 5 and after: limited to 84 mg once weekly for the remainder of the first 12 months of treatment

Documentation requirementRecords must document maintenance dosing frequency and time period consistent with a 12‑month authorization

Temporary frequency exceptionFrequency may be temporarily increased per policy criteria but must return to the 84 mg once‑weekly limit

Substance use disorder in remission — abstinence requirements and modified options

Substance use disorder in remission — primary standardComplete abstinence for at least three months or verification that DSM criteria have not been met for at least 3 months

Modified optionAn alternative option allows at least one month abstinence with agreement to remain abstinent when applicable

Facility confinement optionIf confined 24/7 in a facility where access is impossible, documentation that the individual agreed not to use after discharge may apply

Maintenance dose restated

Maintenance dose (restated)Week 5 and after: esketamine limited to 84 mg once weekly for the rest of the first 12 months; same limit applies on re-authorization for the next 12 months

Temporary increase allowedPolicy permits temporary increase to 84 mg twice weekly when worsening during maintenance, limited in duration and must revert to weekly

Consistency with historyClarified in history entries (12/01/25, 01/01/26) to emphasize 12‑month limits

HCPCS code update definition

HCPCS code update summaryHCPCS code S0013 has been termed and replaced with new HCPCS code J0013 effective January 1, 2026

Coding impactPolicy history indicates coding update; failure to use correct HCPCS codes may lead to coding denials

Documentation noteClaims and prior authorization should reflect the updated J0013 code effective 01/01/2026

Maintenance dosing: Week 5 and after limited to 84 mg once weekly for the first 12 months84 mg once weekly

inv-51: Initial therapy evidence — induction efficacy evidence for TRD and MDD with acute suicidal ideation/behavior

Efficacy evidence for induction in TRD and MDD with acute suicidal ideation or behavior.

Evidence summary for TRD induction: TRANSFORM trials: TRANSFORM-2 (flexible dose) showed significant improvement in MADRS at 4 weeks; TRANSFORM-1 and TRANSFORM-3 did not reach statistical significance though minimum important difference was met in some comparisons

Mixed short-term trial results

Evidence summary for MDD with ASIB induction: Two identical phase 3 short-term studies (Studies 3 & 4) showed esketamine plus comprehensive standard of care was superior to placebo plus standard of care on MADRS at 24 hours after first dose

Secondary suicidal severity measure (CGI-SS-r) did not show superiority

Maintenance evidence: SUSTAIN-1 demonstrated prolonged time to relapse favoring esketamine; SUSTAIN-2 maintained MADRS improvement but had high discontinuation rates

Supports maintenance in select patients per trial design

inv-52: Initial therapy / Induction — induction dosing and initial authorization details

Induction dosing and initial authorization

Induction dosing summary: Induction dosing updated to include an initial dose of 56 mg on first day with subsequent dosing up to 84 mg twice weekly for first 4 weeks per prescribing information; induction dosing must follow FDA prescribing information

Initial authorization may be up to 12 months once criteria met

Documentation for induction: Medical records must include induction dose and frequency and specify time period for induction in documentation submitted for review

History clarified documentation requirements

inv-53: Initial therapy criteria (historical clarifications)

Initial treatment criteria clarified in history

Diagnostic exclusion: No present or past diagnosis of a bipolar disorder and no history of any manic or hypomanic episodes

Added 01/01/26 history entry

Substance use: Current substance use disorder must be in remission or member abstinent for at least one month and agree to remain abstinent (modified options noted in history); later clarification added 3-month remission definition1 month or 3 months per history

Modified and clarified in multiple reviews

Frequency may be temporarily increased per policy if criteria for worsening are met

inv-55: Continuation / maintenance considerations — long-term maintenance, tolerability, SUSTAIN trial data

Long-term maintenance and tolerability considerations from SUSTAIN trials and discontinuation rates.

Maintenance evidence: SUSTAIN-1 showed prolonged time to relapse favoring esketamine; SUSTAIN-2 open-label maintenance showed maintained MADRS improvement but high discontinuation (75.2%)

Supports selective maintenance use

Tolerability and discontinuation: Discontinuation due to adverse events occurred in 5%–16.4% of short-term trials and 5%–9.5% of long-term trials; site-of-care monitoring requirements may affect adherence

Operational consideration for continuation

inv-56: Continuation / Re-authorization notes — continuation and re-authorization specifics

Continuation and re-authorization notes

Maintenance/re-authorization: Maintenance dose after week 4 limited to 84 mg once weekly for the remainder of the first 12 months; the same 84 mg once weekly limit applies for re-authorization for the next 12 months. Frequency may be increased to twice weekly temporarily if depression worsens during maintenance per policy criteria84 mg once weekly

Improvement during maintenance can be documented via symptoms or standardized scales

Documentation requirements: Medical records must document induction dose and maintenance dose frequency and time period, and reasons for prior medication failures must be specified either per medication or collectively

Clarified in history entries

inv-57: Continuation therapy — re-authorization and continuation rules clarified in history

Re-authorization and continuation rules clarified in history entries

Continuation maintenance dose limit: Maintenance dose limited to 84 mg once weekly for the next 12 months upon re-authorization84 mg once weekly

Clarified for re-authorization in history

Induction: up to 84 mg twice weekly; Maintenance: 84 mg once weekly (with temporary exceptions)

Authorization relevanceQuantity limits applied in prior authorization and documentation requirements for both induction and maintenance phases

Spravato dosing (84 mg) restated

Spravato 84 mg reference84 mg is the referenced dose used for induction and maintenance limits throughout the policy

Use in dosing statementsPolicy statements consistently cite 84 mg for allowable dosing (twice weekly induction; once weekly maintenance)

Implication for prescribingPrescribers must adhere to 84 mg dose limits and frequency constraints documented in medical records to meet authorization criteria

Documentation Required

Supervised setting and concurrent substance restrictions

Administer Spravato in a supervised health‑care setting and ensure restrictions on concurrent substances and other site‑of‑care requirements are met and documented per policy.

No concurrent use of hallucinogens/psychedelics, illicit drugs, or non‑prescribed stimulants
Document adherence to site‑of‑care and substance restrictions

Step Therapy

Temporary increase in frequency allowed when depression worsens

A temporary increase in frequency to twice per week is allowed during maintenance for up to 8 weeks when the member's depression has worsened and policy criteria for temporary increased frequency are met; document the clinical change and time‑limited plan.

Temporary dosing limit: 84 mg twice weekly for no more than 8 weeks, then return to 84 mg once weekly
Document worsening from remission/mild or from moderate to severe using symptoms or standardized scales