Does Blue Cross Blue Shield cover Spravato? The short answer is yes – but it depends on your specific plan and meeting certain criteria. We’ll delve into the details below, but please double check with Blue Cross Blue Shield or your local insurance provider to confirm coverage details.
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 Blue Cross Blue Shield Cover Spravato?
Navigating the insurance landscape for mental health treatments like Spravato can be complex. If you’re wondering, does Blue Cross Blue Shield cover Spravato?, the answer is yes, but with some important criteria to meet.
Criteria for Blue Cross Blue Shield Coverage
To qualify for Blue Cross Blue Shield (BCBS) coverage of Spravato, certain conditions must be met. First, it’s crucial that the individual has a diagnosis of either treatment-resistant depression (TRD) or major depressive disorder (MDD) with acute suicidal thoughts.
For TRD, the patient must have tried at least two different antidepressants without adequate results. This demonstrates the need for alternative treatments like Spravato.
Approval criteria include:
- Diagnosis Confirmation: The patient must have a confirmed diagnosis of TRD or MDD.
- Inadequate Response to Antidepressants: Proof of inadequate response to at least two antidepressant medications.
- Psychiatric Evaluation: A thorough psychiatric evaluation is necessary to assess the suitability of Spravato.
- REMS Program Enrollment: The healthcare provider, pharmacy, and patient must be registered with the Risk Evaluation and Mitigation Strategy (REMS) program. This ensures safe administration and monitoring.
How to Get Approved for Spravato Treatment
Once you’ve determined that you meet the criteria, the next step is the approval process for Spravato treatment under BCBS. Here’s a simple guide to steer this process:
- Doctor’s Request: Your healthcare provider will need to submit a request to BCBS, explaining why Spravato is medically necessary for your condition.
- Psychiatric Assessment: A detailed psychiatric assessment will be performed to confirm your diagnosis and ensure Spravato is the right treatment for you.
- Physical Exam: A physical exam may be required to rule out any contraindications for using Spravato.
- Insurance Verification: Contact BCBS to verify your coverage specifics. Coverage can vary by state and plan, so it’s important to confirm details with your provider, as well as ensuring the treatment center you choose is in-network with BCBS.
- Treatment Center Registration: Ensure that the treatment center administering Spravato is registered with the REMS program. If you live in Utah, Anew Therapy is a trusted REMS-certified Spravato provider. If you don’t live in Utah, you can click here to search REMS-certified centers.
Be sure to follow all of the above steps, as doing so will increase your chances of obtaining approval for Spravato treatment under Blue Cross Blue Shield.
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 Blue Cross Blue Shield (BCBS), Medicaid, Medicare, 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.
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 BCBS, 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.
SelectHealth
For a confirmed diagnosis of treatment-resistant depression and major depressive disorder, SelectHealth offers coverage for Spravato (esketamine) under certain conditions:
- 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.
Aetna, Cigna, and United Healthcare
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.
United Healthcare 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. Blue Cross Blue Shield (BCBS), Medicaid, and Medicare 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.
