CommercialPrior AuthHigh impact
Esketamine (Spravato) (CPB 0950, reviewed 2026-02-25)
Aetna·Psychiatry, Internal Medicine, Family Medicine·Medical Policy
Effective date
Feb 25, 2026
We identified it
Aug 13, 2026
Summary
Aetna updated its Esketamine (Spravato) coverage policy (CPB 0950) effective February 25, 2026, establishing new clinical criteria for coverage of this nasal spray for treatment-resistant depression (TRD) and major depressive disorder with acute suicidal ideation. The policy requires mandatory precertification for all administrations, specifies that treatment must be psychiatrist-prescribed and provider-supervised with 2-hour post-administration monitoring, and limits continuation therapy to 6 months for TRD and 4 weeks for acute suicidal ideation cases. Billing teams must implement prior authorization workflows and ensure proper documentation of clinical criteria at point of service.
Action Required
By February 25, 2026: (1) Billing team must configure billing system to REQUIRE precertification for all Esketamine claims before submission—contact Aetna at (866) 752-7021 or fax (888) 267-3277 for precertification authorization using Statement of Medical Necessity forms from Specialty Pharmacy Precertification. (2) Update encounter templates and clinical documentation requirements to capture: standardized depression rating scale scores (BDI, HDRS, or MADRS), psychiatrist name/specialty confirmation, documented 2-hour post-administration monitoring, and for TRD cases—evidence of two antidepressant trials from different classes at maximized doses for ≥8 weeks each OR documented augmentation therapy trial for ≥8 weeks OR evidence-based psychotherapy completion. (3) For acute suicidal ideation cases, require documentation of: current suicidal ideation with intent to act within 24-48 hours, psychiatrist statement that acute psychiatric hospitalization would be required without Spravato, and concurrent oral antidepressant prescription. (4) Providers must confirm members do not have untreated moderate/severe substance or alcohol use disorder. (5) Configure billing system to reject claims using G2082/G2083/J0013 without valid precertification. (6) Flag claims for TRD continuation after 6 months and acute suicidal ideation cases after 4 weeks for medical review denial. Failure to obtain precertification will result in claim denials; claims submitted without required clinical documentation will be rejected.