Does Select Health cover Spravato? The short answer is yes—but coverage depends on your specific plan and meeting certain criteria. We’ll delve into the details further down, but please double-check with Select Health 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 Select Health Cover Spravato?
Navigating insurance coverage for mental health treatments like Spravato can be overwhelming. If you’re wondering, does Select Health cover Spravato?, the answer is yes—for most commercial and Medicare Advantage plans—but only when certain criteria are met. Select Health Community Care (Medicaid), however, does not currently cover Spravato.
Criteria for Select Health Coverage
To qualify for Spravato coverage under Select Health, patients must meet specific clinical and administrative requirements, including:
- Diagnosis Confirmation: A confirmed diagnosis of treatment-resistant depression (TRD) or major depressive disorder (MDD) with acute suicidal ideation.
- Inadequate Response to Antidepressants: Documentation showing the patient has not responded to at least two different oral antidepressants, each given at adequate doses and durations.
- Psychiatric Oversight: Spravato must be prescribed by, or in consultation with, a licensed psychiatrist.
- REMS Program Enrollment: The patient, prescribing clinician, dispensing pharmacy, and treatment center must all be enrolled in the FDA-mandated Risk Evaluation and Mitigation Strategy (REMS) program for Spravato.
- Prior Authorization: Required for all eligible Select Health plans, including Commercial, CHIP, and Medicare Advantage.
For specifics about your plan, visit Select Health’s plan lookup tool.
How to Get Approved for Spravato Treatment with Select Health
If you or your provider believe you’re a good candidate for Spravato, follow these steps to improve your chances of getting approved:
- Schedule a Psychiatric Evaluation: This helps confirm the diagnosis of TRD or MDD and ensures Spravato is medically appropriate for your situation.
- Document Medication History: Provide clear documentation of previous antidepressant trials and outcomes to show insufficient response.
- Submit Prior Authorization: Your healthcare provider must submit a prior authorization request to Select Health, including clinical notes and justification for treatment.
- Verify Coverage Details: Call Select Health or log into your member portal to confirm your specific plan’s benefits, deductible, and network requirements. Coverage can vary by plan and region.
- Choose a REMS-Certified Treatment Center: Ensure the facility administering Spravato is REMS-certified. If you’re in Utah, Anew Therapy is an in-network, REMS-certified provider for most Select Health plans. You can also search for other certified centers here.
Following these steps carefully will improve your chances of receiving approval for Spravato treatment under your Select Health plan.
Comparing Coverage: Select Health, Medicaid, Medicare, and Other Providers
When it comes to covering Spravato and other esketamine treatments, the landscape can vary slightly between Select Health 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.
Select Health
We went into more detail in the previous section, but here’s a quick sum up:
- Confirmed Diagnosis: a confirmed diagnosis of treatment-resistant depression and major depressive disorder is required.
- 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.
- 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.
- 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.
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 likeSelect Health, 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.
Aetna, Cigna, and UnitedHealthcare
For Aetna, coverage for Spravato is given if deemed medically necessary when several criteria are met, including a confirmed diagnosis of MDD or TRD, the patient being 18 years or older, and the medication being administered under medical supervision. The drug must be used in conjunction with an oral antidepressant.
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 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. Select Health, Blue Cross Blue Shield (BCBS), Medicaid, Medicare, Aetna, 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.
