Does UnitedHealthcare cover Spravato? The short answer is yes — but coverage depends on meeting specific clinical criteria and obtaining prior authorization. We’ll break down the details below, but please double-check with UnitedHealthcare or your specific insurance plan to confirm your coverage.
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 UnitedHealthcare Cover Spravato?
Navigating insurance coverage for mental health treatments like Spravato can be complex. If you’re wondering, does UnitedHealthcare cover Spravato?, the answer is yes—when specific clinical criteria are met. UnitedHealthcare considers Spravato medically necessary for eligible patients with treatment-resistant depression (TRD) or major depressive disorder (MDD) with acute suicidal ideation or behavior. However, approval is contingent on strict documentation and prior authorization.
Criteria for UnitedHealthcare Coverage
To qualify for Spravato coverage under UnitedHealthcare, patients must meet specific clinical and administrative requirements, including:
- Confirmed Diagnosis: A diagnosis of treatment-resistant depression (TRD) or MDD with acute suicidal ideation or behavior, as defined by the current DSM criteria.
- Failed Antidepressant Trials: Documentation showing the patient has not responded to at least two different oral antidepressants, each prescribed at adequate doses and durations.
- Psychiatric Oversight: The prescription must be initiated and managed by a licensed mental health professional.
- Concurrent Oral Antidepressant: For MDD with acute suicidal ideation or behavior, Spravato must be used in combination with a newly initiated or optimized oral antidepressant.
- REMS Program Compliance: All parties involved—patient, prescriber, pharmacy, and treatment center—must be enrolled in the FDA’s Spravato Risk Evaluation and Mitigation Strategy (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 with documentation of diagnosis, medication history, and medical necessity. Authorization is typically issued for 12 months.
For specifics about your plan, visit UnitedHealthcare’s plan lookup tool.
How to Get Approved for Spravato Treatment with UnitedHealthcare
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 assessment will document diagnosis and determine clinical appropriateness for Spravato.
- Compile Medication History: Include the names, doses, and durations of past antidepressants, along with outcomes.
- Initiate Prior Authorization: Your provider must submit detailed records through UnitedHealthcare’s prior authorization portal or contact the pharmacy benefits manager handling esketamine coverage.
Verify Coverage Details: Use your UnitedHealthcare member portal or call customer service to confirm plan eligibility, in-network providers, and any copayment responsibilities. - Choose a REMS-Certified Clinic: Ensure the facility administering Spravato is REMS-certified. If you’re located in Utah, Anew Therapy is certified and experienced in guiding UnitedHealthcare members through the process. For other locations, search the REMS directory.
Following these steps carefully will improve your chances of receiving approval for Spravato treatment under your UnitedHealthcare plan.
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 UnitedHealthcare 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.
UnitedHealthcare
We went into more detail in the previous section, but here’s a quick sum up:
- Coverage: Spravato is covered for adults with treatment-resistant depression (TRD) or MDD with suicidal ideation.
- Criteria: Requires failure of three antidepressants, diagnosis consistent with DSM-5-TR, and use with an oral antidepressant.
- Authorization: Prior authorization required; initial approval typically lasts 12 months.
- REMS Compliance: Treatment must be administered in a REMS-certified clinic with at least 2 hours of monitoring.
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 UnitedHealthcare, 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:
- 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
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
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 UnitedHealthcare, it must be used in combination with an oral antidepressant.
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 United Healthcare 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.
