ModifiedPremera BluecrossPolicy 5.01.34

Spravato (esketamine) Nasal Spray — Coverage Criteria

Defines medical necessity, coverage limits, and documentation/coding requirements for Spravato (esketamine) nasal spray for treatment of major depressive disorder (adult patients) under the payer's pharmacy and medical benefits.

Policy Summary

PayerPremera Bluecross

PolicySpravato (esketamine) Nasal Spray — Coverage Criteria

Policy CodePolicy 5.01.34

Change TypeMaterial clinical and administrative revisions

Effective DateJul 7, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with DSM-5 diagnosis, documentation of prior failed antidepressant trials, named concomitant oral antidepressant, and induction/maintenance dosing schedule.

SourceLink

POLICY UPDATE CHANGES

Criteria for coverage of Spravato for MDD with acute suicidal ideation or behavior that were separate from criteria for coverage of Spravato for MDD have been removed; MDD criteria now apply regardless of suicidality.

Documentation requirement updated to include induction dose and maintenance dose frequency and time period specified.

Updated substance use and concomitant drug guidance requiring no current substance use disorder unless in remission and prohibiting concurrent use of hallucinogens/psychedelics and illicit/non-prescribed stimulants around treatment.

Added an option for induction dosing beginning with 56 mg on day 1 then up to 84 mg twice weekly for the first 4 weeks.

Increased the initial authorization period for Spravato to 12 months and aligned re-authorization period to 12 months regardless of formulary status.

Clarified that substance use disorder in remission is defined as complete abstinence or meeting no DSM criteria for at least three months.

Specified that Spravato in any formulation other than the approved nasal spray is investigational.

Deleted separate criteria and items for acute suicidal ideation or behavior, consolidating criteria into main medical necessity sections.

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.

18+minimum age for coverage

3 trialsrequired failed antidepressant trials

84 mgmaximum maintenance dose (weekly)

12 moinitial/re-authorization length

4 BBWsblack box warnings

HCPCS: 62082/62083/S0013codes listed

Coverage Criteria for Spravato (esketamine) Nasal Spray

Initial therapy (Medical Necessity)

Covered when ALL of the following are met:

Age: Individual is aged 18 years or older>=18 years

Diagnosis: Medical record documentation of DSM-5 diagnostic criteria for major depressive disorder without psychotic features (unipolar, not bipolar)

Severity: Current episode of depression is moderate to severe as demonstrated by documentation of symptoms and/or standardized depression rating scale scores

Documentation of symptoms or rating scale required; diagnosis code severity alone insufficient

Psychosis exclusion: No current or past psychosis

Substance use: No current substance use disorder unless in remission (complete abstinence for at least 3 months) OR Confined 24/7 in a facility where access to alcohol/non-prescribed drugs is not possible and individual has agreed to abstain after discharge>=3 months remission if applicable

Concurrent substances/drugs: No concurrent use of 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 using alcohol or marijuana, individual agrees to either cease use while being treated or to avoid use within 24 hours before and 24 hours after each Spravato treatment24 hours

Prior pharmacotherapy: Tried and failed three antidepressants from at least two different classes OR tried and failed two antidepressants from two different classes plus an augmenting agent

Failed trial = not effective, partially/inadequately effective, initially effective then lost effectiveness, or stopped due to intolerable adverse effects; augmenting agents include second-generation antipsychotics, lithium, anticonvulsant mood stabilizers

Dosing limits: Induction dosing (weeks 1–4) limited to 84 mg twice weekly OR 56 mg on day 1 followed by up to 84 mg twice weekly for 4 weeks; Maintenance dosing (week 5 and after) limited to 84 mg once weekly84 mg maintenance

Dosing must follow FDA prescribing information and policy limits

Repeat course (new induction course) coverage

A new induction course may be considered medically necessary when ALL of the following are met:

Prior course eligibility: Individual previously met coverage criteria for Spravato and completed a prior course of treatment

Prior response: Individual had a positive clinical response to the previous Spravato course

Interval since last treatment: Time since the last Spravato treatment exceeds the interval specified in policy (medical record must document timing)

Exact interval to be documented in medical record; policy text references time since last treatment

Current severity and exclusions: Current episode is moderate to severe; no current or past psychosis; substance use and concurrent substance/drug restrictions per initial criteria apply

Investigational / Not Medically Necessary

Investigational uses: Uses not outlined in this policy are investigational, including but not limited to: treatment of chronic pain, bipolar depression, use in conjunction with neuromodulation modalities (e.g., TMS, ECT, VNS), or use with other ketamine formulations or any psychedelic drug

Spravato subject to FDA dosing and administration; other formulations are investigational

Multiple providers: Concurrent provision of Spravato by more than one provider/group/clinic at the same time is considered not medically necessary

Alternate formulations: Esketamine or ketamine formulations other than Spravato nasal spray (e.g., IV, IM, SC, oral) are considered investigational for the treatment of conditions addressed in this policy

Initial and ongoing medical necessity

Covered when ALL of the following are met

Unified MDD coverage criteria: DSM-5 diagnosis of major depressive disorder without psychotic features; age ≥18; prior treatment history consistent with TRD when applicable; no current substance use disorder unless in remission (complete abstinence ≥3 months) or confined 24/7 in a facility where access to substances is impossible and agreement to abstain after discharge; no concurrent use of hallucinogens/psychedelics or illicit/non-prescribed stimulants or other disallowed substances; Spravato to be used in conjunction with a named oral antidepressant; documentation includes induction dose and maintenance dose frequency and time period; administration in a REMS-qualified setting with at least 2-hour post-dose monitoring

Separate criteria previously specific to acute suicidal ideation/behavior have been removed — unified criteria now apply to individuals with or without acute suicidality.

Initial and ongoing therapy coverage criteria

Covered when ALL of the following are met (summary of policy evolution and current requirements reflected in history):

Medical necessity general: DSM-5 diagnosis of major depressive disorder without psychotic features; documentation of prior failed medication trials with reasons for failure and duration (each failed trial identified and documented, generally ≥30 continuous days unless stopped for intolerable adverse effects); Spravato used in conjunction with a named oral antidepressant; no current substance use disorder unless in remission (≥3 months) or patient confined 24/7 in a facility where access to substances is not possible; no concurrent use of hallucinogens/psychedelics, illicit drugs, or non-prescribed stimulants; adherence to dosing limits per FDA prescribing information including induction and maintenance dosing (induction up to 84 mg twice weekly or 56 mg then up to 84 mg twice weekly for 4 weeks; maintenance up to 84 mg once weekly); initial and re-authorization periods may be issued up to 12 months

This node summarizes key elements from policy history; full policy contains additional operational details and documentation requirements.

Spravato (esketamine) is considered investigational and not eligible for coverage when used for indications or combinations not described in this policy. Examples explicitly listed include treatment of bipolar depression and chronic pain, and use in conjunction with neuromodulation modalities such as TMS, ECT, or VNS. The policy also considers use of Spravato together with other formulations of ketamine (e.g., IV, IM, SC, oral) or with any psychedelic drug to be investigational. Such uses may be denied as investigational under the payer's authorization process.

Contraindications that preclude use of Spravato include aneurysmal vascular disease, arteriovenous malformation (AVM), a history of intracerebral hemorrhage, and hypersensitivity to esketamine, ketamine, or any excipients. Additionally, safety concerns highlighted by the product labeling — including risks of sedation, dissociation, and abuse/misuse — require treatment in a REMS-certified setting with post-dose monitoring, and these contraindications must be verified in the medical record prior to administration.

Any formulation of esketamine other than the approved Spravato nasal spray (for example, intravenous, intramuscular, subcutaneous, or oral esketamine) is explicitly considered investigational for the conditions addressed in this policy and is excluded from coverage.

Concurrent use of Spravato with other formulations of ketamine or with psychedelic drugs is considered investigational. Requests for combined or overlapping ketamine/psychedelic regimens may be denied on that basis.

Concurrent treatment by more than one provider, group, or clinic at the same time for administration of Spravato is considered not medically necessary and may be denied. The policy requires a single responsible treating provider or clinic for authorization and billing.

When an individual meets the policy's age and diagnosis requirements but does not meet other specified medical necessity criteria (for example, required prior medication trials, documentation elements, or dosing/monitoring requirements), the request for Spravato is considered not medically necessary and may be denied.

If an individual meets age and diagnosis thresholds but fails to provide required supporting documentation — such as DSM-5 diagnostic documentation, each failed medication trial named with reasons for failure and duration, or the named concomitant oral antidepressant and induction/maintenance dosing details — the use is considered not medically necessary.

The policy reiterates that provision of Spravato by more than one provider/group/clinic at the same time is not medically necessary. Duplicate concurrent provider billing or simultaneous treatment episodes are not covered.

Coding and Monitoring Details

HCPCS codes listedHCPCS

62082	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.
62083	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.
S0013	Esketamine; nasal spray (Spravato), mg

No explicit codes listed in this sectionmixed

No codes listed

Covered HCPCS Codes (as referenced in history)HCPCS

G2082	HCPCS code added (policy history)
G2083	HCPCS code added (policy history)
S0013	HCPCS code added (policy history)

MADRS severity cutoffs

MADRS total score ranges0-6: No depression; 7-19: Mild; 20-34: Moderate; 35-60: Severe

Scale description10-item scale with total score range 0 to 60 used to assess depression severity

Use in policyRequired documentation may include MADRS score to demonstrate moderate-to-severe depression

HAM-D severity cutoffs (17-item HAM-D ranges)

HAM-D (17-item) score ranges0-7: No depression; 8-16: Mild; 17-23: Moderate; 24+: Severe

Scale description17-item clinician-rated scale with total score range 0 to 52 used to determine depression severity

Prior Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior Authorization Required

Prior authorization is required for Spravato (esketamine) for the treatment of depression. Initial authorizations (first course or a repeat course) and re-authorizations may each be approved for up to 12 months when all medical necessity criteria are met and documentation supports ongoing benefit.

Initial and re-authorization approval length: up to 12 months.
Prior authorization is required before treatment is provided.

Prior Authorization

Prior Authorization and Re-authorization

Requests for authorization must include documentation that demonstrates the individual meets medical necessity criteria at the time of the request and at re-authorization. Re-authorization approvals require chart notes documenting continued clinical benefit (improvement in signs/symptoms), maintenance of improvement (not wearing off), absence of serious or dangerous side effects, and adherence to dosing limits.

Re-authorization requires documentation of clinical benefit/response and maintenance of improvement.

Background and Evidence Summary

Major depressive disorder is common and a substantial subset of individuals do not adequately respond to standard antidepressant therapies. In clinical development, Spravato (esketamine) has been studied as an adjunct to a newly initiated oral antidepressant for treatment-resistant depression (TRD) and for MDD with acute suicidal ideation or behavior. Phase 3 trials included multiple randomized studies (TRANSFORM series and SUSTAIN trials) showing mixed results for short-term symptom outcomes and some evidence supporting relapse-prevention in longer-term studies. Following a comprehensive March 2025 evidence review, separate coverage criteria specific to acute suicidal ideation or behavior were removed and the policy now applies unified MDD coverage criteria regardless of suicidality.

Definitions and Key Terms

Treatment-resistant depression (TRD) definition as used in trials

TRD (trial definition) used in esketamine studiesTRD defined in trials as major depressive disorder in individuals who have failed to respond to multiple antidepressants for the current episode (variously defined across studies)

Trial contextTRANSFORM trials enrolled individuals with moderate-to-severe TRD randomized to esketamine plus a new oral antidepressant vs placebo plus a new oral antidepressant

Long-term maintenance evidenceSUSTAIN trials evaluated relapse prevention after induction/optimization phases in individuals with TRD

Failed trial — definition of inadequate response or intolerance

Definition of a failed trialNot effective, partially but inadequately effective, initially effective then lost effectiveness, or stopped due to intolerable side effects; trials of medications commonly used for insomnia count only if dosed at minimum antidepressant levels

Initial Authorization Criteria

Initial therapy — authorization criteria for Spravato as an adjunct to oral antidepressant for adults with MDD

Initial authorization criteria for Spravato as an adjunct to a newly initiated or optimized oral antidepressant for adults with major depressive disorder:

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

Severity: Current episode moderate to severe demonstrated by symptoms and/or standardized depression rating scales

Prior treatment requirement: Tried and failed three antidepressants from at least two classes OR tried and failed two antidepressants from two classes plus an augmenting agent

Failed trial defined in policy; augmenting agents include SGAs, lithium, anticonvulsant mood stabilizers

Re-authorization and Continuation Criteria

Re-authorization / continuation criteria

Re-authorization may be approved up to 12 months when clinical benefit is maintained.

Clinical benefit: Chart notes documenting improvement in signs and symptoms of major depressive disorder and that improvement is being maintained (not wearing-off)

Safety: Individual is not experiencing any serious or dangerous side effects

Substance use: No current substance use disorder unless in remission (complete abstinence for at least 3 months) OR confined 24/7 in a facility as specified; concurrent substance/drug restrictions apply>=3 months

Prior Trial Requirements

Prior trial requirement	Details / policy wording
Failure of three antidepressants from at least two different classes
{"text":"Policy states: ""Tried and failed three antidepressants from at least two different classes OR tried and failed two antidepressants from two different classes plus an augmenting agent"" (indicates required prior pharmacotherapy before Spravato is considered medically necessary).","status":""}

Adjunctive therapy requirement	Policy detail
Spravato must be used with an oral antidepressant (adjunctive therapy)
Policy: re-authorization and continuation require Spravato to be used in conjunction with an oral antidepressant; documentation must specify the named oral antidepressant to be used with Spravato.

Documentation requirement	Policy / historical revision
Each failed antidepressant trial must be individually identified with reason(s) for failure and duration of at least 30 continuous days unless stopped for intolerable adverse effects
History note: documentation requirement added (effective Feb 3, 2023) specifying each failed medication named, reason(s) for failure, and at least 30 continuous days of use; policy also requires documentation of induction dose and maintenance dose/frequency/time period.

Administration Setting and Monitoring

Billing Rule

Office administration under direct supervision with observation

Spravato must be administered under the direct supervision of a healthcare provider with post‑administration observation as part of the treatment session.

Documentation Required

REMS enrollment required; at least 2‑hour post‑dose monitoring

Administration must occur in a REMS‑enrolled healthcare setting with monitoring for at least 2 hours after each treatment session and assessment for clinical stability before discharge.

Monitor for at least 2 hours post‑dose
Assess clinical stability before departure

Policy Summary

PayerPremera Bluecross

PolicySpravato (esketamine) Nasal Spray — Coverage Criteria

Policy CodePolicy 5.01.34

Change TypeMaterial clinical and administrative revisions

Effective DateJul 7, 2025

Next Review DateN/A

Key ActionSubmit prior authorization with DSM-5 diagnosis, documentation of prior failed antidepressant trials, named concomitant oral antidepressant, and induction/maintenance dosing schedule.

SourceLink

On This Page

Policy noteDiagnosis code severity alone is insufficient; documentation of symptoms or standardized rating scale (e.g., HAM-D) score is required

Monitoring duration per REMS (post-dose observation requirement)

Required post-dose monitoringIndividuals must be monitored for 2 hours after each treatment session per REMS

Clinical stability assessmentPatients must be assessed for clinical stability before departure from the treatment setting

Observation timing in trialsSymptoms peaked at ~40 minutes; majority were discharge-ready by 1.5 hours in trials

Substance use disorder remission definition

Remission definitionComplete abstinence for at least 3 months or verification that none of the current DSM diagnostic criteria for a substance use disorder have been met for at least 3 months

Alternate facility conditionIf confined 24/7 in a facility where access to alcohol/non-prescribed drugs is impossible, individual must agree to abstain after discharge

Policy applicationNo current substance use disorder unless in remission as specified; clarified in multiple history entries

Dose limits must follow FDA prescribing information (induction and maintenance dosing).

Denial Risk

Multiple Concurrent Providers

Spravato administered by more than one provider, group, or clinic at the same time is considered not medically necessary and may be denied.

Concurrent treatment by multiple providers/groups/clinics is not medically necessary.

Denial Risk

Not Meeting Policy Medical Necessity

Requests that do not meet the policy medical necessity criteria will be considered not medically necessary and may be denied. Uses not outlined in this policy (including age or diagnosis that do not meet the Medical Necessity section) are considered investigational and may be denied.

Not meeting age or DSM-5 diagnosis requirements = investigational and may be denied.
Meeting age/diagnosis but failing other required criteria = not medically necessary and may be denied.

Denial Risk

Not Meeting Policy Criteria Triggers Denial

If the request does not meet all policy criteria (for example, lack of required prior trials, missing documentation of concomitant oral antidepressant, or concurrent disallowed substance use), the request may be denied as not medically necessary.

Failure to meet step-therapy or trial adequacy requirements may trigger denial.
Missing documentation supporting medical necessity (see Documentation Requirements) may trigger denial.

Documentation Required

Required Medical Record Documentation

Medical records submitted for authorization must document that medical necessity criteria are met. Required documentation includes office visit notes with diagnosis, relevant history, physical evaluation, and medication history; documentation of induction and maintenance dosing (frequency and time period) consistent with a 12-month authorization; and detailed records for each failed medication trial.

Office visit notes with diagnosis, history, physical exam, and medication history.
Documentation of induction dosing (weeks 1–4) and maintenance dosing (week 5 and after) with frequency and time period specified.
Documentation must support a 12-month authorization period.

Documentation Required

Concomitant Antidepressant Must Be Named

The oral antidepressant that will be used in conjunction with Spravato for ongoing therapy must be specifically named in the documentation submitted for authorization.

Concomitant oral antidepressant name and dosing must be included in the record.

Step Therapy

Step Therapy Prior Trials

Step therapy requirements: individuals must have tried and failed three antidepressants from at least two different classes, OR two antidepressants from two different classes plus an augmenting agent (e.g., second-generation antipsychotic, lithium, anticonvulsant used as a mood stabilizer). Each failed medication must be individually identified with reasons for failure and documentation of adequate trial duration (at least 30 continuous days at therapeutic dose unless stopped earlier for intolerable adverse effects).

Three antidepressant trials from at least two classes OR two antidepressants from two classes plus an augmenting agent.
Each failed medication must be listed with reason(s) for failure and dose/duration details (≥30 continuous days at adequate dose unless stopped for intolerance).
Augmenting agents include second-generation antipsychotics, lithium, and anticonvulsants used as mood stabilizers.

Prior Authorization

Concomitant Oral Antidepressant Requirement

For continued (ongoing) Spravato therapy, Spravato must be used in conjunction with a named oral antidepressant; this concomitant oral antidepressant requirement is mandatory for re-authorization and ongoing maintenance therapy.

Concomitant oral antidepressant is required for ongoing therapy and must be named in documentation.
If the individual uses alcohol or marijuana, they must either cease use during treatment or not use within 24 hours before and 24 hours after each Spravato treatment.

Step Therapy

Prior Antidepressant Trial Requirements

Prior antidepressant trial requirements must include: identification of each antidepressant trial, the class of the drug, dose and duration, reason for failure (ineffective, inadequate effect, loss of effect, or intolerable side effects), and verification that trials used antidepressant-level dosing (some agents commonly used for insomnia count only if given at antidepressant doses).

Each failed medication must be identified with specific reasons for failure and dose/duration.
Trials of agents used for insomnia count only if given at minimum antidepressant doses (examples provided in policy).

Documentation requirementsEach failed medication must be individually identified and the reason(s) for failure specified; at least 30 continuous days of use is required unless stopped for intolerable adverse effects

Augmentation noteSecond-generation antipsychotics, lithium, and anticonvulsant mood stabilizers are considered augmenting agents (not antidepressants) when used as augmenters

TRD contextual definition referencing TRANSFORM and SUSTAIN trials

Contextual TRD definitionTRD in TRANSFORM and SUSTAIN trials referred to moderate-to-severe depression with inadequate response to prior antidepressant trials in the current episode

Study designTRANSFORM trials: 4-week randomized, double-blind, active-controlled studies assessing change in MADRS with esketamine plus a new oral antidepressant vs placebo plus a new oral antidepressant

Maintenance evidenceSUSTAIN-1 was a withdrawal study assessing time to relapse; SUSTAIN-2 was an open-label long-term safety/maintenance study

MDD with acute suicidal ideation or behavior — trial enrollment context (ASPIRE/Study 3/4)

Enrollment context for suicidal trialsASPIRE/Study 3 and Study 4 enrolled adults with MDD and active suicidal ideation/intent who received esketamine plus comprehensive standard of care, including newly initiated or optimized oral antidepressant and initial inpatient hospitalization as indicated

Dosing and durationTwice-weekly esketamine (84 mg) for 4 weeks with an allowed one-time reduction to 56 mg for intolerance; follow-up continued through day 90

Onset of effect observedTreatment differences vs placebo were observed starting at 4 hours post-dose; primary efficacy measured by MADRS change at 24 hours

Substance use disorder in remission definition

Substance use disorder in remissionComplete abstinence for at least 3 months or verification that none of the current DSM diagnostic criteria for a substance use disorder have been met for at least 3 months

Facility exceptionIf confined 24/7 in a facility where access to alcohol/non-prescribed drugs is not possible, treatment may proceed provided the individual agrees to abstain after discharge while continuing Spravato

Policy historyRemission timeframe and related rules were clarified in multiple policy history entries (2023–2025) to require ≥3 months abstinence or DSM criteria verification

Major depressive disorder (policy definition) — DSM-5 criteria for unipolar MDD without psychotic features

Policy definition of MDDDSM-5 diagnostic criteria for major depressive disorder without psychotic features (unipolar; not bipolar) are required for documentation

Severity requirementCurrent episode must be moderate to severe demonstrated by symptoms and/or standardized depression rating scale scores (diagnosis code severity alone is insufficient)

ExclusionsNo current or past psychosis; no current substance use disorder unless in remission as specified; concurrent use of hallucinogens/illicit or non-prescribed stimulants prohibited

Concurrent oral antidepressant: Spravato must be used in conjunction with a named oral antidepressant (documentation must specify the antidepressant)

Dosing/administration requirements: Induction dosing limited to 84 mg twice weekly (or 56 mg on day 1 then up to 84 mg twice weekly for 4 weeks); maintenance dosing limited to 84 mg once weekly (week 5 and after); administered in REMS-enrolled healthcare setting with at least 2-hour monitoring post-dose84 mg maintenance; 2 hours monitoring

Dosing must follow FDA prescribing information

Initiation evidence context

Evidence context for initiation (trial-level summary):

Short-term TRD trials: Phase 3 TRANSFORM trials (1–3) randomized individuals with moderate to severe TRD to esketamine plus a new oral antidepressant vs placebo plus a new oral antidepressant; results were mixed (TRANSFORM-2 positive on MADRS, TRANSFORM-1 and TRANSFORM-3 not statistically significant though some arms met minimal important difference)

Clinical trials support mixed short-term efficacy for TRD; providers should consider trial evidence when assessing likely benefit

Suicidality trials: Two identical 4-week phase 3 trials in individuals with acute suicidal ideation/behavior showed statistical superiority on MADRS at 24 hours for esketamine plus standard of care versus placebo plus standard of care; secondary outcomes were mixed

Policy history concluded separate suicidality-specific coverage criteria were removed after comprehensive review

Induction dosing

Initial induction dosing options per policy update:

Induction dosing option A: Induction dosing limited to 84 mg twice weekly for weeks 1–4 (per FDA prescribing information)

Induction dosing option B: Option added (Sept 2024): 56 mg on day 1 followed by up to 84 mg twice weekly for the first 4 weeks

Added in 2024 interim review

Maintenance dose prescribed (week 5 and after) is limited to 84 mg once weekly

Re-authorization

Re-authorization requires meeting ongoing medical necessity and continued use with an oral antidepressant.

Re-authorization requirements: Member continues to meet initial criteria; documentation of response to prior course if applicable; named oral antidepressant remains prescribed and is documented; dosing and monitoring records (including induction dose and maintenance dose frequency/time period) provided

Policy updates require naming the concomitant oral antidepressant and documenting induction/maintenance dosing

Re-authorization / Continuation summary from policy history

Continuation and re-authorization requirements summarized from policy history.

Continuation: Members continuing on Spravato must continue to meet medical necessity criteria, including ongoing use with a named oral antidepressant and absence of active substance use disorder unless in remission; re-authorization period may be issued up to 12 months

Documentation must include maintenance dose frequency and duration; each failed medication trial must be identified with reasons for failure

Note

Coverage subject to benefit limits; policy not applicable to Medicare Advantage

Coverage decisions are subject to the member's benefit limits and site‑of‑care specifics governed by the benefit plan; this policy does not apply to Medicare Advantage.