Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT POLICY | 1

(401) 274-4848 WWW.BCBSRI.COM

EFFECTIVE DATE: 06|01|2024 POLICY LAST REVIEWED: 05|01|2024

OVERVIEW

Food and Drug Administration (FDA) Approved Indications: Spravato® (esketamine) nasal spray is a non- competitive N-methyl D-aspartate (NMDA) receptor antagonist indicated, in conjunction with an oral antidepressant, for the treatment of:

• Treatment-resistant depression (TRD) in adults
• Depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior. Spravato® (esketamine) is only available through a REMS (Risk Evaluation Mitigation Strategies) program. Spravato® must be administered under direct supervision of a healthcare provider. Spravato® (esketamine) is a Schedule III controlled substance.

MEDICAL CRITERIA and LIMITATIONS (Click here.) • Approval for Treatment-Resistant Depression is limited to 12 weeks (3 months). Reauthorization for
continuation of treatment for Treatment-Resistant Depression is limited to 12 months.
• Approval for management of depressive symptoms associated with acute suicidal ideation or behavior is limited to 4 weeks.
• The Plan does not cover Spravato® (esketamine) for any indications other than those listed in the Medical Necessity Guidelines.

PRIOR AUTHORIZATION

Prior authorization is required through Prime Therapeutics. Prior Approval Request Form (click here).

POLICY STATEMENT

Blue Cross & Blue Shield of Rhode Island (BCBSRI) has payment policies for various drugs and biologicals that are covered under the member’s medical coverage. This will ensure that claims are paid in accordance with industry standard coding practices, generally accepted clinical guidelines and in a consistent manner across the network. These edits do not take the place of prior authorization when that is required. They are applied to claims to screen for coding errors and dosage that exceeds generally accepted limits.

All claim submissions remain subject to Blue Cross & Blue Shield of Rhode Island prior authorization requirements.

COVERAGE Benefits may vary between groups and contracts. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable drug benefits/coverage.

  Payment Policy | Spravato® (esketamine) nasal spray

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 PAYMENT POLICY | 2

(401) 274-4848 WWW.BCBSRI.COM

CODING Codes The following code(s) require prior authorization:

HCPCS Codes Description

    G2082

Drug + service for up to 56mg: Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare provider and provision of up to 56 mg of esketamine nasal self-administration, includes 2 hours post-administration observation

    G2083

Drug + service for doses greater than 56mg (84mg): Office or other outpatient visit for the evaluation and management of an established patient that requires the supervision of a physician or other qualified healthcare provider and provision of greater than 56 mg of esketamine nasal self-administration, includes 2 hours post- administration observation.

RELATED POLICIES Drugs and Biologicals Payment Policy

PUBLISHED Provider Update, June 2024

REFERENCES:

1. Spravato® (esketamine) Nasal Spray http://www.spravatohcp.com

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association.