Navigating Spravato Coverage: Aetna

Does Aetna cover Spravato? The short answer is yes—but coverage depends on meeting certain criteria. We’ll delve into the details further down, but please double-check with Aetna or your local insurance provider to confirm coverage specifics.

Understanding Spravato and Its Uses

What is Spravato?

Spravato is a nasal spray containing esketamine, an FDA-approved medication. It’s used to treat treatment-resistant depression (TRD) and major depressive disorder (MDD) with acute suicidal ideation. Unlike traditional antidepressants, Spravato offers a new approach for those who haven’t responded to at least two other treatments.

Esketamine, the active ingredient, is a form of ketamine, a drug originally used as an anesthetic. Its approval by the FDA in 2019 marked a significant advancement in mental health treatment, providing a new option for individuals struggling with severe depression.

How Does Spravato Work?

Spravato works by targeting NMDA receptors in the brain. These receptors are part of a complex network that influences mood and cognition. By acting as an NMDA receptor antagonist, Spravato helps to restore connections between brain cells, potentially offering rapid symptom relief.

This mechanism is different from typical antidepressants, which usually take weeks to show effects. Spravato can start working within hours, making it a vital option for those in urgent need of relief.

The treatment involves nasal administration of esketamine, which is done in a healthcare setting. It’s used in combination with an oral antidepressant to improve effectiveness.Before starting Spravato, patients undergo a thorough psychiatric assessment to ensure it’s the right choice for them. This includes evaluating their history of depression and previous treatment responses.

Spravato’s unique approach and rapid action have made it a preferred choice for many seeking quick and effective relief from severe depression. It provides hope to those who have not found success with other treatments, offering a new path to mental wellness. 

Does Aetna Cover Spravato?

If you’re asking, does Aetna cover Spravato?, the answer is yes—when specific clinical conditions are met. Aetna considers Spravato medically necessary for eligible patients with treatment-resistant depression (TRD) or major depressive disorder (MDD) with acute suicidal ideation. However, approval is contingent on strict documentation and prior authorization.

Criteria for Aetna Coverage

To be approved for Spravato coverage through Aetna, all of the following criteria typically must be satisfied:

• Confirmed Diagnosis: The patient must have a diagnosis of treatment-resistant depression (TRD) or MDD with suicidal ideation.
• Age Requirement: The patient must be 18 years or older.
• Failed Antidepressant Trials: The patient must have had an inadequate response to at least two antidepressants from different pharmacologic classes, each prescribed at therapeutic doses for a minimum of six weeks.
• Psychiatric Oversight: The prescription must be initiated and managed by a psychiatrist.
• Concurrent Oral Antidepressant: Spravato must be used in combination with an oral antidepressant.
• REMS Program Compliance: All parties involved—patient, prescriber, pharmacy, and treatment center—must be registered with the FDA’s Spravato REMS program.
• Clinical Monitoring: The treatment must occur in a certified healthcare setting with at least two hours of monitoring per dose.
• Prior Authorization: Required and reviewed under Aetna’s pharmacy policy; documentation must include clinical notes, failed medication trials, and rationale for esketamine use.

For specifics about your plan, visit Aetna’s plan lookup tool.

How to Get Approved for Spravato Treatment with Aetna

Here’s a step-by-step guide to streamline the approval process with Aetna:

1. Request a Psychiatric Evaluation: This assessment will document diagnosis and determine clinical appropriateness for Spravato.
2. Compile Medication History: Include the names, doses, and durations of past antidepressants, along with outcomes.
3. Initiate Prior Authorization: Your provider must submit detailed records through Aetna’s prior authorization portal or contact the pharmacy benefits manager (PBM) handling esketamine coverage.
4. Verify Coverage: Use your Aetna member portal or call customer service to confirm plan eligibility, in-network providers, and any copayment responsibilities.
5. Choose a REMS-Certified Clinic: You must receive treatment at a REMS-certified center. If you’re located in Utah, Anew Therapy is certified and experienced in guiding Aetna members through the process. For other locations, search the REMS directory.

Comparing Coverage: Blue Cross Blue Shield, Medicaid, Medicare, and Other Providers

When it comes to covering Spravato and other esketamine treatments, the landscape can vary slightly between Aetna and other providers. Each has its own criteria and processes for approval, which can affect accessibility for patients with treatment-resistant depression or major depressive disorder.

Aetna

We went into more detail in the previous section, but here’s a quick sum up:

1. Confirmed Diagnosis: A diagnosis of treatment-resistant depression (TRD) or major depressive disorder (MDD) with suicidal ideation is required.
2. Age Requirement: The patient must be 18 or older.
3. Coverage: Spravato is covered when deemed medically necessary and used in combination with an oral antidepressant.
4. Clinical Criteria: Must show failed response to at least two oral antidepressants at adequate dose and duration.
5. Prescribing Provider: Must be initiated and managed by a psychiatrist.
6. Administration: Treatment must occur in a REMS-certified healthcare setting with observation and safety protocols.
7. Prior Authorization: Required with documentation of diagnosis, medication history, and medical necessity.
8. REMS Compliance: Patient, provider, pharmacy, and facility must all be enrolled in the Spravato REMS program.

No two insurance companies are the same when it comes to Spravato coverage, but there tends to be many overlapping criterias. Read on to learn the key differences between insurance providers.

Blue Cross Blue Shield Coverage Details

Blue Cross Blue Shield provides coverage for Spravato, but you must have a confirmed diagnosis of treatment-resistant depression (TRD) or major depressive disorder (MDD) with acute suicidal ideation.

Coverage can vary by state and plan, which means that while some BCBS plans might cover Spravato with ease, others might have more stringent requirements. For example, BCBS in Utah and Massachusetts tend to have clearer policies for ketamine treatments compared to states like North Carolina or Kansas, where claims are often denied.

Medicaid and Medicare Coverage

Medicaid and Medicare also offer coverage for esketamine treatments, but like Aetna, they have their own specific criteria. Medicaid’s coverage is often state-dependent, meaning each state has its own rules and processes. Generally, Medicaid also requires a confirmed diagnosis of TRD or MDD and evidence of inadequate response to traditional antidepressants.

Medicare covers Spravato under Part B, as it is administered by a healthcare provider. Medicare patients must have a diagnosis of TRD or MDD, and the treatment must be deemed medically necessary. Approval processes involve thorough documentation and often require prior authorization.

Both Medicaid and Medicare emphasize the importance of the REMS program for Spravato, ensuring that the treatment is administered safely and effectively. This program requires healthcare providers, pharmacies, and patients to be registered, providing an extra layer of safety and monitoring.

Select Health

For a confirmed diagnosis of treatment-resistant depression and major depressive disorder, Select Health offers coverage for Spravato (esketamine) under certain conditions:

1. Commercial Plans and CHIP: Spravato is covered when billed directly through Pharmacy with appropriate pre-authorization. Clinic administration and observation costs will need to be billed separately, but should also be covered under this plan.
2. Select Health Advantage: Coverage follows CMS guidelines for the reimbursement of Spravato. This includes requirements for prior authorization, documentation of medical necessity, and adherence to treatment protocols such as REMS certification.
3. Select Health Community Care: Spravato is not covered under this plan.

For all plans, prior authorization is necessary, and Spravato administration must be billed in a specific manner. It’s also essential for the healthcare professionals prescribing and administering Spravato to comply with the REMS program.

Cigna

Cigna’s policy also requires a confirmed diagnosis of MDD or TRD, and Spravato must be prescribed by a psychiatrist. The treatment must involve baseline clinical assessments and is only approved for use in a certified healthcare facility. Like Aetna, it must be used in combination with an oral antidepressant​.

UnitedHealthcare

UnitedHealthcare requires a diagnosis according to DSM-5-TR criteria, trial and failure of three different antidepressant medications, and detailed baseline clinical scoring. Authorization can be given for an initial 12-month period, with the possibility of renewal based on positive clinical response and continued need. Spravato must be used in conjunction with an oral antidepressant, and the healthcare provider must be certified in the Spravato REMS program​.

Costs can vary depending on the plan and the provider, but insurance generally covers a significant portion of the treatment. Always check directly with your insurance provider for the most accurate and personalized coverage information.

Conclusion

Navigating insurance coverage for Spravato can seem overwhelming, but understanding the basics can make the process smoother. Aetna, Select Health, Blue Cross Blue Shield (BCBS), Medicaid, Medicare, Cigna, and UnitedHealthcare all offer pathways to cover this innovative treatment for individuals with treatment-resistant depression and major depressive disorder.

For those exploring treatment options, Anew Therapy Utah offers both Spravato and intramuscular (IM) ketamine therapy, focusing on rapid symptom relief and a holistic approach to mental health. We accept most insurance providers for Spravato treatment, and we are REMS certified. Our team is dedicated to providing personalized treatment plans that cater to each individual’s unique needs and budget. If you’re considering Spravato, learn more here and see how we can support you on your journey to better mental health. Our commitment to patient-centric care ensures that you receive the most effective and compassionate treatment possible.