Criteria
Coverage is subject to the specific terms of the member's benefit plan.
Federal Employee Program members (FEP) should check with their Retail Pharmacy Program to determine if prior approval is required by calling the Retail Pharmacy Program at 1-800-624-5060 (TTY: 1-800-624-5077). FEP members can also obtain the list through the
www.fepblue.org
website.
Esketamine (Spravato) may be considered medically necessary when ALL of the following criteria are met:
-
ONE (1) of the following:
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BOTH of the following:
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The individual has a diagnosis of Treatment-Resistant Depression;
and
-
The individual has tried and had an inadequate response to at least two (2) different oral antidepressants (e.g., TCAs, SSRIs, SNRIs);
or
-
The individual has a diagnosis of major depressive disorder (MDD) with acute suicidal ideation or behavior;
or
-
The individual has another FDA approved indication for esketamine (Spravato);
and
-
If the individual has an FDA approved indication, ONE (1) of the following:
-
The individual's age is within FDA labeling for the requested indication for esketamine (Spravato);
or
-
The prescriber has provided information in support of using esketamine (Spravato) for the individual's age for the requested indication;
and
-
The prescriber is a specialist in the area of the individual's diagnosis (e.g., psychiatrist) or the prescriber has consulted with a specialist in the area of the individual's diagnosis;
and
- Esketamine (Spravato) will be used in combination with an oral antidepressant.
Reauthorization Criteria
Esketamine (Spravato) may be considered medically necessary when ALL of the following criteria are met:
-
The individual has previously been approved for esketamine (Spravato) through Blue Cross Blue Shield of North Dakota's precertification process;
and
-
The prescriber has provided documentation that the individual has demonstrated disease stability or beneficial response to therapy;
and
-
The prescriber is a specialist in the area of the individual's diagnosis (e.g., psychiatrist) or the prescriber has consulted with a specialist in the area of the individual's diagnosis;
and
- Esketamine (Spravato) will be used in combination with an oral antidepressant.
The use of esketamine (Spravato) for all other indications not listed in this policy is considered experimental/investigational and therefore non-covered because the safety and/or effectiveness cannot be established by the available published peer-reviewed literature.
Procedure Code
