CurrentViva Health PlanPolicy IC-0481

Spravato (esketamine) (Intranasal)

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This policy governs prior authorization, coverage criteria, dosing limits, administration, renewal, and billing requirements for Spravato (esketamine) nasal spray for adults with major depressive disorder. It applies to Viva Health Plan commercial and Medicare fee-for-service members and their providers.

Policy Summary

PayerViva Health Plan

PolicySpravato (esketamine) (Intranasal)

Policy CodePolicy IC-0481

Change TypeNo material change

Effective DateN/A

Last ReviewAug 4, 2026

Next Review DateN/A

Key ActionAdminister Spravato under direct healthcare-provider supervision with post-administration observation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+Minimum member age

6 monthsInitial authorization validity

12 monthsRenewal authorization validity

2Failed antidepressant trials required for treatment-resistant depression

2 hours

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CurrentViva Health PlanPolicy IC-0481

Spravato (esketamine) (Intranasal)

Customize your policy alerts

Sign up for vivahealthplan Policy IC-0481 alerts

Get alerted when Policy IC-0481 changes without checking for updates manually.

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Policy Summary

PayerViva Health Plan

PolicySpravato (esketamine) (Intranasal)

Policy CodePolicy IC-0481

Change TypeNo material change

Effective DateN/A

Last ReviewAug 4, 2026

Next Review DateN/A

Key ActionAdminister Spravato under direct healthcare-provider supervision with post-administration observation.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

18+Minimum member age

6 monthsInitial authorization validity

12 monthsRenewal authorization validity

2Failed antidepressant trials required for treatment-resistant depression

2 hours

Post-administration observation

17Covered diagnosis codes

Coverage Criteria

Universal Initial Criteria

Initial authorization requires all universal criteria.

Universal initial criteria

Member is at least 18 years old.Age >= 18
Member has a diagnosis of major depressive disorder according to the current version of the Diagnostic and Statistical Manual of Mental Disorders.
Member has a baseline assessment using a validated depression rating scale, such as MADRS, HAM-D, PHQ-9, BDI, or QIDS.
The policy accepts any validated depression rating scale.
Member does not have an FDA-labeled contraindication to Spravato, including aneurysmal vascular disease, arteriovenous malformation, history of intracerebral hemorrhage, or hypersensitivity to esketamine, ketamine, or any excipient.
Member is not receiving concomitant ketamine therapy.

Treatment-Resistant Depression

Initial authorization for treatment-resistant depression requires all criteria.

Treatment-resistant depression

Spravato is used as monotherapy or in conjunction with an oral antidepressant.
Member has tried psychotherapy alone or in combination with an oral antidepressant when psychotherapy resources are available.
Member is not receiving concomitant electroconvulsive therapy, transcranial magnetic stimulation, vagus nerve stimulation, or deep brain stimulation.
Member has failed a trial of at least two antidepressants from different classes for at least 6 weeks each, with adequate adherence at generally accepted doses during the current depressive episode, unless a trial was contraindicated or associated with clinically significant adverse effects.At least 2 antidepressants; different classes; >= 6 weeks each; <= 25% symptom reduction defines failure
A failed trial is defined as a reduction in symptom severity of 25% or less using any validated depression rating scale.

MDD With Acute Suicidal Ideation or Behavior

Initial authorization for depressive symptoms in MDD with acute suicidal ideation or behavior requires the oral-antidepressant condition and at least one acute pathway.

MDD with acute suicidal ideation or behavior

Spravato must be used in conjunction with an oral antidepressant.
Qualifying acute pathway
- Member is experiencing acute suicidal ideation or behavior.
- Member has recently been discharged from a hospital in which treatment with esketamine was initiated.

Renewal Therapy

Renewal requires all criteria.

Renewal criteria

Member continues to meet the universal and indication-specific initial criteria.
Member has no unacceptable toxicity from the drug.
Examples include sedation, dissociation, respiratory depression, signs of abuse or dependence, severe cognitive impairment, ulcerative or interstitial cystitis, suicidal thoughts or behavior, and severe hypertension.
Member has demonstrated disease improvement or stabilization compared with baseline using a validated depression rating scale.Improvement or stabilization versus baseline

Coverage requires that the member have no FDA-labeled contraindication to Spravato (esketamine), including aneurysmal vascular disease involving the thoracic or abdominal aorta, intracranial or peripheral arteries; arteriovenous malformation; a history of intracerebral hemorrhage; or hypersensitivity to esketamine, ketamine, or any excipient.

The member must not be receiving concomitant ketamine therapy. For treatment-resistant depression, the member also must not be receiving electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), vagus nerve stimulation (VNS), or deep brain stimulation (DBS).

Coding and Billing Codes

HCPCS Drug CodeHCPCSCovered

J0013

Esketamine, nasal spray, 1 mg; 1 billable unit = 1 mg

HCPCS Administration and Observation CodesHCPCSCovered

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 postadministration 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 postadministration observation

NDCsNDCCovered

50458-0028-xx	56 mg Dose Kit: Unit-dose carton containing two 28 mg nasal spray devices (56 mg total dose)
50458-0028-xx	84 mg Dose Kit: Unit-dose carton containing three 28 mg nasal spray devices (84 mg total dose)

Covered Diagnosis CodesICD-10Covered

F32.0	Major depressive disorder, single episode, mild
F32.1	Major depressive disorder, single episode, moderate
F32.2	Major depressive disorder, single episode, severe without psychotic features
F32.3	Major depressive disorder, single episode, severe with psychotic features
F32.4	Major depressive disorder, single episode, in partial remission
F32.5	Major depressive disorder, single episode, in full remission
F32.9	Major depressive disorder, single episode, unspecified
F33.0	Major depressive disorder, recurrent, mild
F33.1	Major depressive disorder, recurrent, moderate
F33.2	Major depressive disorder, recurrent severe without psychotic features

1–10 of 17

1/2

Treatment-Resistant Depression Induction Dosing

G2082/G20831 billable unit twice weekly during weeks 1–4

J001384 billable units twice weekly during weeks 1–4

Treatment phaseInduction for treatment-resistant depression

Treatment-Resistant Depression Maintenance Dosing

G2082/G20831 billable unit weekly beginning week 5

J001384 billable units weekly beginning week 5

Authorization and Provider Requirements

Prior Authorization

Prior Authorization Duration

Prior authorization is required. Initial authorization is valid for 6 months (180 days), and renewal authorization may be issued every 12 months (365 days).

Billing Rule

Supervised Administration and Billing

Administer Spravato only under the direct supervision of a healthcare provider, including post-administration observation during each treatment session. For Medicare Part B claims, report the applicable administration code with the drug; non-Medicare providers that do not accept the G codes may report separate drug and service codes.

G2082: established-patient visit with supervision and provision of up to 56 mg, including 2 hours of post-administration observation.

Policy Background

Spravato (esketamine) is an intranasal therapy covered for adults with major depressive disorder in two policy-defined settings: treatment-resistant depression and depressive symptoms associated with major depressive disorder with acute suicidal ideation or behavior. Treatment-resistant depression requires inadequate response to prior antidepressant therapy, while the acute suicidal ideation or behavior pathway requires concurrent oral antidepressant therapy. Administration requires direct healthcare-provider supervision and post-administration observation.

Definitions

Failed Trial

DefinitionA failed antidepressant trial is a reduction in symptom severity of 25% or less

Assessment methodUse any validated depression rating scale

ApplicationThe failed-trial standard applies to prior antidepressant therapy for treatment-resistant depression

Treatment Session

AdministrationNasal administration of Spravato

SupervisionTreatment must occur under the direct supervision of a healthcare provider

Observation

Initial Therapy Criteria

Initial Therapy - Treatment-Resistant Depression

Initial treatment for treatment-resistant depression requires all universal and indication-specific criteria.

Initial treatment—treatment-resistant depression

Member is at least 18 years old.Age >= 18
Member has a diagnosis of major depressive disorder according to the current version of the Diagnostic and Statistical Manual of Mental Disorders.
Member has a baseline assessment using a validated depression rating scale, such as MADRS, HAM-D, PHQ-9, BDI, or QIDS.
Member does not have an FDA-labeled contraindication to Spravato, including aneurysmal vascular disease, arteriovenous malformation, history of intracerebral hemorrhage, or hypersensitivity to esketamine, ketamine, or any excipient.

Continuation and Renewal Criteria

Renewal Criteria

Renewal requires all continuation criteria.

Continuation therapy

Universal and indication-specific initial criteria continue to be met.
Unacceptable toxicity from the drug is absent.
Examples include sedation, dissociation, respiratory depression, signs of abuse or dependence, severe cognitive impairment, ulcerative or interstitial cystitis, suicidal thoughts or behavior, and severe hypertension.
Disease improvement or stabilization is demonstrated compared with baseline using a validated depression rating scale.Improvement or stabilization versus baseline

Step Therapy Requirements

Step	Requirement	Duration / Additional Details
1	Failure of at least two antidepressants from different classes at generally accepted doses with adequate adherence during the current depressive episode	At least 6 weeks for each antidepressant; failure is defined as a reduction in symptom severity of 25% or less on a validated depression rating scale. Exceptions apply for contraindication or clinically significant adverse effects.

Step	Requirement	Duration / Additional Details
2	Trial of psychotherapy alone or in combination with an oral antidepressant for treatment-resistant depression	Required when psychotherapy resources are available.

Quantity and Frequency Limits

Spravato Quantity Limits: G2082/G2083

Induction, weeks 1–41 G2082/G2083 billable unit twice weekly

Maintenance, week 5 and after1 G2082/G2083 billable unit weekly

IndicationSpravato for treatment-resistant depression

Spravato Quantity Limits: J0013

Induction, weeks 1–484 J0013 billable units twice weekly

Maintenance, week 5 and after84 J0013 billable units weekly

IndicationSpravato for treatment-resistant depression

Site of Care and Administration

Note

Use supervised office administration

Administer Spravato in an office under direct healthcare-provider supervision, with post-administration observation during the treatment session.

A treatment session consists of nasal administration followed by post-administration observation under supervision.
The G2082 and G2083 services include 2 hours of post-administration observation.

Policy Summary

PayerViva Health Plan

PolicySpravato (esketamine) (Intranasal)

Policy CodePolicy IC-0481

Change TypeNo material change

Effective DateN/A

Last ReviewAug 4, 2026

Next Review DateN/A

Key ActionAdminister Spravato under direct healthcare-provider supervision with post-administration observation.

SourceLink

On This Page

Treatment phaseMaintenance during week 5 and after

MDD With Acute Suicidal Ideation or Behavior

G2082/G20832 billable units weekly

J0013168 billable units weekly

IndicationDepressive symptoms in major depressive disorder with acute suicidal ideation or behavior

G2083: established-patient visit with supervision and provision of greater than 56 mg, including 2 hours of post-administration observation.

J0013: esketamine nasal spray, 1 mg; 1 billable unit equals 1 mg.

Prior Authorization

Prior Authorization Factors

Prior authorization is an applicable non-quantitative treatment limitation for this drug/drug group. Utilization-management factors were considered comparably, and not more stringently, for mental health/substance use disorder and medical/surgical medical-benefit prescription drugs.

Indication: considered for prior authorization.
Safety and efficacy: considered for prior authorization.
Potential for misuse or abuse: considered for prior authorization.
Cost of drug: considered for prior authorization.

Step Therapy

Psychotherapy and Oral Antidepressant Prerequisites

For treatment-resistant depression, document that Spravato is used as monotherapy or with an oral antidepressant and that the member has tried psychotherapy alone or with an oral antidepressant when psychotherapy resources are available.

Documentation Required

Universal Eligibility Documentation

Document universal eligibility before requesting authorization, including the member's age, diagnosis, and absence of FDA-labeled contraindications.

Member is at least 18 years old.
Member has major depressive disorder diagnosed under the current DSM criteria.
Member does not have an FDA-labeled contraindication to esketamine, including aneurysmal vascular disease, arteriovenous malformation, history of intracerebral hemorrhage, or hypersensitivity to esketamine, ketamine, or an excipient.

Documentation Required

Baseline Depression Assessment

Include a baseline assessment using a validated depression rating scale before initial approval.

Acceptable examples include MADRS, HAM-D, PHQ-9, BDI, and QIDS.

Documentation Required

Treatment-Resistant Depression History

For treatment-resistant depression, document prior psychotherapy, when resources are available, and the required antidepressant treatment history in the current depressive episode.

Document psychotherapy alone or combined with an oral antidepressant, if psychotherapy resources are available.
Document trials of at least two antidepressants from different classes, each for at least 6 weeks, with adequate adherence and generally accepted dosing, unless contraindicated or limited by clinically significant adverse effects.

Documentation Required

Acute Suicidal Ideation or Behavior Documentation

For the acute suicidal ideation or behavior indication, document the qualifying acute presentation or recent hospital discharge and confirm that Spravato is used with an oral antidepressant.

Document current acute suicidal ideation or behavior; or
Document recent discharge from a hospital where esketamine treatment was initiated.

Documentation Required

Renewal Documentation

For renewal, document continued eligibility under the universal and indication-specific criteria, absence of unacceptable toxicity, and objective improvement or stabilization compared with baseline.

Use a validated depression rating scale to document reduced symptom severity compared with baseline.
Address toxicity, including sedation, dissociation, respiratory depression, signs of abuse or dependence, severe cognitive impairment, ulcerative or interstitial cystitis, suicidal thoughts or behavior, and severe hypertension.

Denial Risk

FDA-Labeled Contraindication

Authorization may be denied when the member has an FDA-labeled contraindication to Spravato.

Examples include aneurysmal vascular disease, arteriovenous malformation, history of intracerebral hemorrhage, or hypersensitivity to esketamine, ketamine, or an excipient.

Denial Risk

Prohibited Concomitant Therapy

Authorization may be denied when prohibited concomitant therapy is documented.

Do not use with concomitant ketamine therapy.
For treatment-resistant depression, do not use with concomitant ECT, TMS, VNS, or DBS.

Denial Risk

Insufficient Antidepressant Trials

Authorization may be denied when the member has not failed at least two qualifying antidepressant trials in the current depressive episode, unless a trial was contraindicated or stopped for clinically significant adverse effects.

Trials must involve antidepressants from different classes, last at least 6 weeks each, and include adequate adherence at generally accepted doses.
A failed trial means a reduction in symptom severity of 25% or less on a validated depression rating scale.

Denial Risk

Unsuccessful Renewal

Renewal may be denied when unacceptable toxicity is present or when the member has not demonstrated sufficient improvement or stabilization compared with baseline.

Document absence of unacceptable toxicity.
Document reduced symptom severity or stabilization using a validated depression rating scale.

Billing Rule

Dosing or Unit Limit Exceeded

Claims may be denied when billed units or administration frequency exceed the policy limits for the indication and treatment phase.

TRD induction, weeks 1–4: 1 G2082/G2083 billable unit twice weekly; J0013: 84 billable units twice weekly.
TRD maintenance, week 5 and after: 1 G2082/G2083 billable unit weekly; J0013: 84 billable units weekly.
MDD with acute suicidal ideation or behavior: 2 G2082/G2083 billable units weekly; J0013: 168 billable units weekly.
For TRD, administer 56 mg or 84 mg twice weekly during weeks 1–4, then weekly during weeks 5–8; from week 9 onward, use weekly or every-2-week dosing individualized to the least frequent effective frequency.
For MDD with acute suicidal ideation or behavior, administer 84 mg twice weekly for 4 weeks; the dose may be reduced to 56 mg twice weekly based on tolerability.

Post-administration observation is part of the treatment session

Member is not receiving concomitant ketamine therapy.

Spravato is used as monotherapy or in conjunction with an oral antidepressant.

Member has tried psychotherapy alone or in combination with an oral antidepressant when psychotherapy resources are available.

Member is not receiving concomitant electroconvulsive therapy, transcranial magnetic stimulation, vagus nerve stimulation, or deep brain stimulation.

Member has failed a trial of at least two antidepressants from different classes for at least 6 weeks each, with adequate adherence at generally accepted doses during the current depressive episode, unless a trial was contraindicated or associated with clinically significant adverse effects.At least 2 failed antidepressant trials; <= 25% symptom reduction

A failed trial is defined as a reduction in symptom severity of 25% or less using any validated depression rating scale.

Initial Therapy - Acute Suicidal Ideation or Behavior

Initial treatment for depressive symptoms in MDD with acute suicidal ideation or behavior requires all universal criteria, the oral-antidepressant condition, and at least one qualifying acute pathway.

Initial treatment—acute suicidal ideation or behavior

Member is at least 18 years old.Age >= 18
Member has a diagnosis of major depressive disorder according to the current version of the Diagnostic and Statistical Manual of Mental Disorders.
Member has a baseline assessment using a validated depression rating scale, such as MADRS, HAM-D, PHQ-9, BDI, or QIDS.
Member does not have an FDA-labeled contraindication to Spravato, including aneurysmal vascular disease, arteriovenous malformation, history of intracerebral hemorrhage, or hypersensitivity to esketamine, ketamine, or any excipient.
Member is not receiving concomitant ketamine therapy.
Spravato is used in conjunction with an oral antidepressant.
Qualifying acute pathway
- Member is experiencing acute suicidal ideation or behavior.
- Member has recently been discharged from a hospital in which treatment with esketamine was initiated.

Spravato Quantity Limits: Acute Suicidal Ideation or Behavior

G2082/G20832 billable units weekly

J0013168 billable units weekly

IndicationSpravato for depressive symptoms in major depressive disorder with acute suicidal ideation or behavior