S0013, Esketamine, nasal spray, 1 mg
HCPCS/CPT
Prior Authorization
No Prior Auth Required
Code is covered without prior authorization (high confidence)
Documentation Required
- Monitor the individual for at least 2 hours after each treatment and assess clinical stability before discharge.
- Administration must occur under the direct supervision of a healthcare provider.
- Blood pressure must be assessed before and after treatment per FDA labeling.
- Advise individuals to avoid food for ≥2 hours and liquids for ≥30 minutes before administration.
Key Coverage Criteria
- Treatment-resistant depression: induction weeks 1-4 — twice weekly dosing (day 1 start 56 mg; subsequent doses 56 mg or 84 mg); maintenance weeks 5-8 — once weekly (56 mg or 84 mg); from week 9 onward — every 2 weeks or once weekly (56 mg or 84 mg); individualize to the least frequent dosing to maintain remission/response.
- Major depressive disorder with acute suicidal ideation or behavior: 84 mg twice weekly for 4 weeks (may reduce to 56 mg twice weekly for tolerability); use beyond 4 weeks has not been systematically evaluated.
- Treatment-resistant depression: induction weeks 1-4 — twice weekly dosing (day 1 start 56 mg; subsequent doses 56 mg or 84 mg); maintenance weeks 5-8 — once weekly (56 mg or 84 mg); from week 9 onward — every 2 weeks or once weekly (56 mg or 84 mg); individualize to the least frequent dosing to maintain remission/response.
- Major depressive disorder with acute suicidal ideation or behavior: 84 mg twice weekly for 4 weeks (may reduce to 56 mg twice weekly for tolerability); use beyond 4 weeks has not been systematically evaluated.
- Treatment-resistant depression: induction weeks 1-4 — twice weekly dosing (day 1 start 56 mg; subsequent doses 56 mg or 84 mg); maintenance weeks 5-8 — once weekly (56 mg or 84 mg); from week 9 onward — every 2 weeks or once weekly (56 mg or 84 mg); individualize to the least frequent dosing to maintain remission/response.
- Major depressive disorder with acute suicidal ideation or behavior: 84 mg twice weekly for 4 weeks (may reduce to 56 mg twice weekly for tolerability); use beyond 4 weeks has not been systematically evaluated.
4 Active Policies
BCBSIL-RX501.105, Esketamine Nasal Spray
BCBSMT-RX501.105, Esketamine Nasal Spray
BCBSNM-RX501.105, Esketamine Nasal Spray
BCBSOK-RX501.105, Esketamine Nasal Spray
Related Codes
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