Does Cigna 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 Cigna 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 Cigna Cover Spravato?
Yes, Cigna covers Spravato (esketamine) for adults diagnosed with treatment-resistant depression (TRD) or major depressive disorder (MDD) with acute suicidal ideation or behavior, provided specific clinical criteria are met. Coverage requires prior authorization and adherence to safety protocols.
Criteria for Cigna Coverage
To qualify for Spravato coverage under Cigna, the following conditions must be met:
- Age Requirement: Patient must be 18 years or older.
- Diagnosis Confirmation: A confirmed diagnosis of TRD or MDD with acute suicidal ideation or behavior.
- Treatment History: Documentation of inadequate response (defined as ≤25% improvement in depression symptoms) to at least two different antidepressants from different pharmacologic classes, each used at therapeutic dosages for a minimum of six weeks during the current depressive episode.
- Concurrent Medication: For MDD with acute suicidal ideation or behavior, Spravato must be used in conjunction with a newly initiated or optimized oral antidepressant.
- Prescribing Provider: Spravato must be prescribed by a psychiatrist or a healthcare provider with appropriate expertise in treating depression.
- REMS Program Compliance: Both the prescribing provider and the treatment facility must be certified under the FDA’s Risk Evaluation and Mitigation Strategy (REMS) program for Spravato.
- Administration Setting: Spravato must be administered in a certified healthcare setting with monitoring for at least two hours post-administration.
- Prior Authorization: Required with comprehensive documentation, including diagnosis, treatment history, and rationale for Spravato use. View the full prior authorization document here.
How to Get Approved for Spravato Treatment with Cigna
To initiate Spravato treatment under Cigna coverage:
- Consultation: Schedule an evaluation with a psychiatrist to confirm diagnosis and assess treatment history.
- Documentation: Gather medical records detailing previous antidepressant trials, including dosages, durations, and responses.
- Prior Authorization Submission: Your healthcare provider will submit a prior authorization request to Cigna, including all necessary documentation.
- Verification: Confirm with Cigna that your treatment facility is in-network and REMS-certified.
- 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 Cigna 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 Cigna 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.
Cigna
We went into more detail in the previous section, but here’s a quick sum up:
- Confirmed Diagnosis: Required diagnosis of treatment-resistant depression (TRD) or major depressive disorder (MDD) with suicidal ideation or behavior.
- Age Requirement: Patient must be 18 or older.
- Treatment History: Must have failed at least two different oral antidepressants at therapeutic doses and durations.
- Concurrent Medication: Must be used with an oral antidepressant, especially in cases of MDD with suicidal ideation.
- Prescribing Provider: A psychiatrist or qualified mental health specialist must oversee treatment.
- REMS Compliance: All parties must be certified under the Spravato REMS program.
- Administration: Must be delivered in a certified healthcare setting with two-hour post-dose monitoring.
- Prior Authorization: Required, with thorough documentation of diagnosis, medication history, and medical necessity.
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 Cigna, 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.
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.
DMBA
While Spravato isn’t explicitly listed as a covered medication under DMBA, coverage may be granted through prior authorization with documentation of medical necessity, including a confirmed diagnosis of TRD or MDD and lack of success with other treatments. Treatment must be REMS-compliant and preferably in-network.
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. Cigna, Select Health, Blue Cross Blue Shield (BCBS), Medicaid, Medicare, Aetna, DMBA, 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.
