Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after October 1, 2019, clinician administered drug esketamine (Spravato) will become a benefit of Texas Medicaid. Providers must submit claims for esketamine (Spravato) with unlisted procedure code J3490.
Esketamine (Spravato) nasal spray is an N-methyl-D-aspartate (NMDA) receptor antagonist that is indicated in adults for the treatment of treatment-resistant depression (TRD), in conjunction with an oral antidepressant.
Esketamine (Spravato) must be prescribed by, or in consultation with a psychiatrist.
Esketamine (Spravato) is only available through a restricted program under a Risk Evaluation and Mitigation Strategy (REMS).
- Providers/health-care settings must be certified in the Spravato REMS program to administer Spravato to clients enrolled in the REMS program. Administration of the drug must take place in a health-care facility under the direct observation of a health-care provider.
- Pharmacies must be certified in the Spravato REMS program to dispense to health-care settings who are authorized to administer the drug.
- Clients must be enrolled in the Spravato REMS program and comply with the ongoing requirements for Spravato treatment.
Prior authorization is required for esketamine (Spravato). Prior authorization may be approved for six months.
Initial therapy for esketamine (Spravato) nasal spray may be approved if the following criteria are met:
- The client is 18 years old or older.
- The client has a diagnosis of major depressive disorder (MDD) (diagnosis code F320, F321, F322, F324, F325, F329, F330, F331, F332, F3340, F3341, or F339).
- The client has TRD that has been confirmed as inadequate response or failure to previous antidepressant treatment.
- The client must receive esketamine (Spravato) nasal spray concomitantly with an oral antidepressant agent (esketamine [Spravato] should not be used as monotherapy).
- Esketamine (Spravato) must be administered under the direct observation of a health-care provider and the client must be monitored for at least 2 hours after each treatment.
- Prior to starting esketamine (Spravato) treatment, there must be an attestation of baseline scoring of clinical assessment of major depressive disorder (MDD).
- The client must not have contraindications to esketamine (Spravato), such as aneurysmal vascular disease, arteriovenous malformation, or intracerebral hemorrhage.
For renewal or continuation therapy, the client must meet all the following requirements:
- The client continues to meet the initial prior authorization approval criteria.
- The client demonstrates positive clinical response to esketamine (Spravato) therapy by an improvement from baseline assessment.
- The client has previously received treatment esketamine (Spravato) without complications.
Prior authorization requests for esketamine (Spravato) (unlisted procedure code J3490) must be submitted with a Special Medical Prior Authorization Request Form.
Documentation of the client’s dosage, administration schedule, number of injections to be administered during the prior authorization period, the requested units per injection, and the dosage calculation must be submitted in Section C of the Special Medical Prior Authorization Request Form under Statement of Medical Necessity.
The Special Medical Prior Authorization Request Form must be completed, signed, and dated by the prescribing provider. The completed form must be maintained by the prescribing provider in the client’s medical record and is subject to retrospective review. The form will not be accepted beyond 90 days from the date of the prescribing provider’s signature.
Esketamine (Spravato) may be reimbursed for medical services rendered to clients who are 18 years old and older in the office or outpatient hospital setting as follows:
Place of Service
Physician assistant/nurse practitioner/clinical nurse specialist, physician, clinic/group practice providers
Hospital – long term, limited, or specialized care, hospital – private, O/P, service/emergency care only
For more information, call the TMHP Contact Center at 800-925-9126.