Navigating Spravato Coverage: DMBA

Does DMBA cover Spravato? The short answer is yes—Spravato can be covered by DMBA, but it requires prior authorization and documentation of medical necessity. Although it’s not explicitly listed under standard plan benefits, coverage is often granted when other treatments have been ineffective. We’ll walk you through the steps below, but be sure to verify the specifics with DMBA or your provider.

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. 

DMBA Does Cover Spravato

Criteria for DMBA Coverage

To explore potential coverage for Spravato under DMBA, the following steps are recommended:

• Preauthorization Requirement: All specialty drugs, including Spravato, require preauthorization. This process involves submitting a request through DMBA’s designated channels, such as Archimedes Rx or Navitus Health Solutions, depending on your specific plan. You can find the full preauthorization guidelines here. If you’re receiving treatment with Anew Therapy, they will handle this entire process on your behalf. 
• Medical Necessity Documentation: Your healthcare provider must submit comprehensive documentation demonstrating the medical necessity of Spravato. This includes a confirmed diagnosis of treatment-resistant depression (TRD) or major depressive disorder (MDD) with acute suicidal ideation, along with evidence of inadequate response to at least two different antidepressant medications.
• REMS Program Compliance: Spravato must be administered in a certified healthcare setting that complies with the FDA’s Risk Evaluation and Mitigation Strategy (REMS) program. Both the prescribing provider and the treatment facility must be REMS-certified.
• In-Network Providers: Utilizing in-network providers is crucial, as DMBA covers in-network services at a higher rate (typically 70%) compared to out-of-network services (typically 50%). Using in-network providers can significantly reduce out-of-pocket costs.  For information about in-network providers in your area for your specific plan, go to www.dmba.com and select Find a Provider.

How to Get Approved for Spravato Treatment with DMBA

1. Consultation: Schedule an evaluation with a psychiatrist to confirm your diagnosis and assess your treatment history.
2. Documentation: Gather medical records detailing previous antidepressant trials, including dosages, durations, and responses.
3. Preauthorization Submission: Your healthcare provider will submit a preauthorization request to DMBA through the appropriate channel (Archimedes Rx or Navitus Health Solutions), including all necessary documentation.
4. Verification: Confirm with DMBA that your treatment facility is in-network and REMS-certified.
5. Approval: Upon approval, coordinate with your provider to schedule treatment sessions in a certified setting.

For residents in Utah, Anew Therapy is a REMS-certified provider experienced in administering Spravato and assisting with DMBA insurance coordination.

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 DMBA 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.

DMBA

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

• Confirmed Diagnosis: A diagnosis of treatment-resistant depression (TRD) or major depressive disorder (MDD) with suicidal ideation is required.
• Coverage Status: Spravato is not explicitly listed as a covered medication, but may be approved through prior authorization on a case-by-case basis.
• Preauthorization Required: All specialty medications, including Spravato, require preauthorization through DMBA or its pharmacy benefit partners (e.g., Archimedes Rx or Navitus).
• REMS Compliance: Treatment must occur at a REMS-certified facility with a REMS-certified provider.
• In-Network Providers: Using in-network providers improves reimbursement rates and reduces out-of-pocket costs.

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 DMBA, 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 DMBA, it must be used in combination with an oral antidepressant​.

Aetna

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​.

EMI Health

EMI Health may cover Spravato with prior authorization if medically necessary, requiring a confirmed diagnosis of TRD or MDD, the patient to be 18 or older, and treatment to be administered under REMS-certified medical supervision 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. DMBA, Select Health, Blue Cross Blue Shield (BCBS), Medicaid, Medicare, Cigna, Aetna, EMI Health 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.