CommercialPrior AuthMedium impact
08.01.80d, Intravenous Ketamine (Ketalar®) and Intranasal Esketamine (Spravato®)
Independence Blue Cross·Psychiatry, Anesthesiology, Pain Management·Pharmacy
Effective date
Dec 29, 2025
We identified it
Jun 19, 2026
Summary
Commercial insurance plans updated medical necessity criteria for intravenous ketamine (Ketalar®) and intranasal esketamine (Spravato®), which may affect prior authorization requirements and coverage determination for these medications used in treatment-resistant depression and other conditions.
Action Required
By December 29, 2025: Billing team must review updated medical necessity criteria for ketamine and esketamine treatments. Update prior authorization processes and ensure documentation requirements align with new criteria. Verify coverage determination procedures with commercial payers to prevent claim denials.