Spravato Coverage and Reimbursement

BCBS Coverage

I. Treatment Resistant Depression

Initial Authorization for 3 Months

1.  Individual is 18 years of age or older; AND
2. Individual meets the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) criteria for a major depressive episode (See Table 1 in Description) by a structured clinical interview for DSM-5 disorders; AND
3. Individual’s current depressive episode is moderate or severe depression based on one of the following:
   • a. Montgomery-Asberg Depression Rating Scale (MADRS) ≥ 28 (see Policy Guidelines), o
   • b. Hamilton Rating Scale for Depression (HAM-D) score ≥ 17 (see Policy Guidelines);
   • c. Patient Health Questionnaire 9 (PHQ-9) score ≥ 10 (see Policy Guidelines); or
   • d. Quick Inventory of Depressive Symptomatology (QIDS) score ≥ 11 (see Policy Guidelines); AND
4. Individual has tried and had an inadequate response to 1 antidepressant agent (i.e., selective serotonin reuptake inhibitor, serotonin and norepinephrine reuptake inhibitor, tricyclic antidepressant, bupropion, or mirtazapine). An adequate trial of an antidepressant is defined by the following:
   • a. The trial length was at least 6 weeks at generally accepted doses, or of sufficient duration as determined by the treating physician at the generally accepted doses; AND
5. Individual does not have a current substance use disorder unless in remission (complete abstinence for a month.)

Reauthorization

Continuation of treatment with esketamine nasal spray (Spravato®) following at least 3 months of use may be reauthorized when ALL of the following conditions are met:

1. Individual has had improvement in depression symptoms as evaluated with an appropriate depression rating scale (e.g., MADRS, HAM-D, PHQ-9, QIDS); AND
2. Individual does not have a current substance use disorder.

II Major Depressive Disorder with Acute Suicidal Ideation or Behavior

Esketamine nasal spray may be considered medically necessary for a treatment period of 28 days when ALL of the following conditions are met:

1. Individual is 18 years of age or older; AND
2. Individual with major depressive disorder with acute suicidal ideation or behavior; AND
3. Individual is to receive esketamine nasal spray in conjunction with an oral antidepressant. Esketamine nasal spray (Spravato®) is considered experimental, investigational and/or unproven in all other situations.