Esketamine (SpravatoTM) is the S-isomer of racemic ketamine and is an antidepressant which is a non-selective, non-competitive antagonist of the N-methyl-D-aspartate (NMDA) receptor (an ionotropic glutamate receptor). Due to adverse events (sedation, dissociation, etc.) an individual must be monitored by a healthcare provider while administering the medication and for at least two hours after administration is complete. Due to the risk of increased blood pressure with administration, the healthcare provider should monitor the individual’s blood pressure before and after treatment.
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 for the treatment of individuals 18 years of age and older when ALL of the following criteria are met:
Esketamine (Spravato) for any other indication is considered experimental/investigational and, therefore, non-covered. Scientific evidence does not support the use of esketamine (Spravato) for any other indication.
NOTE: In addition to the above criteria, product specific dosage and/or frequency limits may apply in accordance with the U.S. Food and Drug Administration (FDA)-approved product prescribing information, national compendia, Centers for Medicare and Medicaid Services (CMS) and other peer reviewed resources or evidence-based guidelines. Blue Cross Blue Shield of North Dakota may deny, in full or in part, reimbursement for utilization that does not fall within the applicable dosage and/or frequency limits.