Spravato (esketamine) — CareFirst (Caremark)

Initial criteria

• Member has a confirmed diagnosis of severe major depressive disorder (single or recurrent episode) documented by standardized rating scales (e.g., BDI, HDRS, MADRS).
• Member age ≥ 18 years.
• Requested medication will be administered under direct supervision of a healthcare provider.
• Member will be monitored by a health care provider for at least 2 hours after administration.
• Medication prescribed by or in consultation with a psychiatrist.
• Coverage will not be provided for members with moderate or severe substance or alcohol use disorder that is not currently being treated or medically managed.
• For treatment-resistant depression (TRD): member has experienced an inadequate response during the current depressive episode with two antidepressants from at least two different classes with different mechanisms of action at the maximally tolerated labeled dose, each used for at least 8 weeks within the past 5 years.
• For TRD: member has experienced an inadequate response with an adequate trial of augmentation therapy for at least 8 weeks within the past 5 years OR evidence-based psychotherapy (CBT, IPT, ST, or PEI) during the current depressive episode.
• Augmentation therapy may include (a) two antidepressants with different mechanisms of action used concomitantly, (b) an antidepressant plus a second-generation antipsychotic, (c) an antidepressant plus lithium, or (d) an antidepressant plus thyroid hormone.
• For MDD with acute suicidal ideation or behavior: member has major depressive disorder with current suicidal ideation with intent defined as (1) thoughts of self-harm with at least some intent or awareness that they may die or (2) thoughts of suicide, AND member intends to act on the thoughts.
• For MDD with acute suicidal ideation or behavior: prescriber represents that, in the absence of the requested drug, within 24–48 hours the member will require confinement in an acute care psychiatric institution.
• For MDD with acute suicidal ideation or behavior: requested drug will be used in combination with an oral antidepressant (e.g., duloxetine, escitalopram, sertraline, venlafaxine).

Reauthorization criteria

• For TRD: authorization may continue if there is improvement or sustained improvement from baseline in depressive symptoms as documented by standardized rating scales (e.g., BDI, HDRS, MADRS).
• For MDD with acute suicidal ideation or behavior: use beyond 4 weeks has not been systematically evaluated; member must continue to meet all coverage criteria.

Approval duration

Initial: 3 months (TRD) or 1 month (MDD with acute suicidal ideation or behavior); Reauthorization: 6 months (TRD)