Medicaid and Spravato: A Comprehensive Guide to Coverage

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Introduction: Understanding Spravato and Its Uses

Spravato (esketamine) is a medication used in treating patients with Major Depressive Disorder (MDD) and suicidal ideation or Treatment Resistant Depression (TRD). It’s often prescribed in conjunction with an oral antidepressant. With many people asking, “Does Medicaid cover Spravato?”, it’s crucial to understand the requirements for coverage.

Criteria for Medicaid Coverage of Spravato

Major Depressive Disorder with Suicidal Ideation

To qualify for initial Medicaid coverage of Spravato for MDD with suicidal ideation, a patient must meet the following criteria:

  1. Be 18 years of age or older.
  2. Have a documented diagnosis of MDD with acute suicidal ideation or behavior requiring immediate intervention.
  3. The medication must be prescribed by a psychiatrist in a Spravato REMS certified center.
  4. Spravato must be used alongside an oral antidepressant (e.g., citalopram, duloxetine, venlafaxine, bupropion, trazodone).
  5. The allowed dosage: 84 mg (1 kit) twice per week for 4 weeks (8 kits total).

If the patient also has a concurrent diagnosis of TRD, they must meet additional criteria to qualify for a longer approval duration. When all requirements are met, Medicaid will approve Spravato coverage for 1 month.

For reauthorization, the continuation of Spravato beyond 4 weeks hasn’t been established for the same episode. If a new suicidal ideation episode arises, patients must follow the initial criteria again.

Treatment Resistant Depression

For initial Medicaid coverage of Spravato for TRD, a patient must meet these conditions:

  1. Be 18 years of age or older.
  2. Have a documented diagnosis of treatment-resistant MDD.
  3. The medication must be prescribed by a psychiatrist in a Spravato REMS certified center.
  4. Spravato must be used in conjunction with an oral antidepressant.
  5. The patient must have tried and failed at least two different oral antidepressants from different drug classes at optimized doses for at least 8 weeks, with one being an SSRI or SNRI.
  6. The patient’s baseline depression status must be documented using an appropriate rating scale (e.g., PHQ-9, BDI, QIDS, MADRS, HAM-D).

When all requirements are met, Medicaid will approve Spravato coverage for 2 months.

For reauthorization, the patient must:

  1. Be compliant with the concomitant use of an oral antidepressant.
  2. Show documented improvement of depressive symptoms as measured by an appropriate rating scale (e.g., PHQ-9, BDI, etc.).

If the patient meets all reauthorization requirements, Medicaid will approve Spravato coverage for an additional 6 months.

Conclusion: Navigating Medicaid and Spravato

In summary, Medicaid does cover Spravato for patients who meet specific criteria related to their diagnosis of MDD with suicidal ideation or TRD. Patients must work closely with their healthcare providers to ensure they fulfill all requirements for initial authorization and reauthorization. By understanding these criteria and adhering to the prescribed treatment plan, patients can potentially access Spravato through Medicaid coverage to help manage their depression.

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