Esketamine Nasal Spray

This policy covers esketamine (Spravato) nasal spray for adults with treatment‑resistant major depressive disorder or MDD with acute suicidal ideation/behavior, administered only in Spravato REMS‑certified pharmacies or healthcare settings and used in conjunction with an oral antidepressant. Coverage is limited to individuals ≥18 with a DSM‑5–confirmed major depressive episode of moderate‑to‑severe severity by standardized scales (e.g., MADRS ≥28, HAM‑D ≥17, PHQ‑9 ≥15, QIDS ≥16), a documented inadequate response to at least one adequate antidepressant trial (generally ≥6 weeks), and approval parameters (initial authorization ~3 months, reauthorization up to 6 months with documented improvement); patients not meeting these criteria (including active substance use disorder, age <18, non‑REMS settings, or benefit‑plan exclusions) are not covered.

"Coverage of any FDA-approved drug when prescribed for a use recognized as safe and effective in one or more standard medical reference compendia adopted by the U."