MedicaidPrior AuthMedium impact
BT202611: IHCP updates PA criteria for esketamine (Spravato) drug codes
Indiana Medicaid (IHCP)·IN · Psychiatry·Pharmacy
Effective date
Oct 1, 2025
We identified it
Jun 18, 2026
Summary
IHCP (Indiana Medicaid) has updated prior authorization criteria for esketamine (Spravato) treatments, effective retroactively to October 1, 2025. The policy establishes specific eligibility requirements for treatment-resistant depression and major depressive disorder with suicidality, and provides billing guidance prohibiting certain code combinations.
Action Required
Immediately: Billing team must update prior authorization protocols for esketamine (Spravato) to verify patient meets new IHCP criteria including diagnosis requirements, age 18+, psychiatrist prescription, REMS enrollment, and contraindication screening. Update billing system to prevent submission of G2082/G2083 with S0013 combinations and E/M codes with G2082/G2083, as these will be denied as medically unnecessary. Submit medical claims to Gainwell Technologies and pharmacy claims to Optum Rx.