Provider Alert! Benefit reminder and Prior Authorization Update for Spravato

Provider Alert!

Provider Alert! Benefit reminder and Prior Authorization Update for Spravato

Attention: Behavioral health Providers

Effective Date: January 1, 2021

Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event.  TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.

Call to action: Texas Children’s Health Plan (TCHP) aligns with the Health and Human Services Commission (HHSC) on the revised prior authorization criteria for Spravato (Esketamine). Effective January 1, 2021, HHSC will revise the Medicaid and CHIP prior authorization criteria for Spravato (Esketamine).

Spravato (Esketamine) is currently used for treatment-resistant depression (TRD). Effective January 1, it will also be a benefit for the treatment of depressive symptoms in adults with major depressive disorder (MDD) with acute suicidal ideation or behavior.

Esketamine (Spravato) is available only as a medical benefit and may be distributed through specialty pharmacy providers with dates of service on or after July 1, 2020. Providers/health care settings, pharmacies, and members must be certified and/or enrolled in the in the Spravato Risk and Evaluation Mitigation Strategy (REMS) program.

References: Outpatient Drug Services Handbook
TMHP notice dated June 5, 2020

How this impacts providers: Patients must meet the following requirements for approval of therapy:

  • Be 18 years of age or older
  • Have a diagnosis of MDD (diagnosis code F320, F321, F322, F324, F325, F329, F330, F331, F332, F3340, F3341, F3342 or F339)
  • Have a prescriber’s evaluation show suicidal ideation with intent, or the person needs acute psychiatric hospitalization due to the imminent risk of suicide
  • Receive Esketamine (Spravato) nasal spray concomitantly with an oral antidepressant agent (Esketamine [Spravato] should not be used as monotherapy)
  • Have a healthcare provider administer Esketamine (Spravato) under direct observation, and the provider must monitor for at least 2 hours after each treatment session
  • Have an attestation of baseline scoring of clinical assessment of MDD before starting Esketamine (Spravato) treatment
  • Not have contraindications to Esketamine (Spravato), such as aneurysmal vascular disease, arteriovenous malformation, or intracerebral hemorrhage

Next steps for providers: Providers should communicate these changes to their staff.

If you have any questions, please email Provider Network Management at:

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