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 January 1, 2021, prior authorization criteria for esketamine (Spravato) will be updated for Texas Medicaid.
In addition to the current indication for treatment of treatment-resistant depression, esketamine (Spravato) will also be a benefit for the treatment of depressive symptoms in adult clients with major depressive disorder with acute suicidal ideation or behavior. For initial prior authorization approval, the following criteria must be met:
- The client is 18 years of age 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, F3342 or F339).
- The prescriber’s evaluation must show the client has suicidal ideation with intent, or needs acute psychiatric hospitalization due to imminent risk of suicide.
- 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 session.
- Prior to starting esketamine (Spravato) treatment, there must be an attestation of baseline scoring of clinical assessment of MDD.
- The client must not have contraindications to esketamine (Spravato), such as aneurysmal vascular disease, arteriovenous malformation, or intracerebral hemorrhage.
Refer to: The current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 7.28, “Esketamine (Spravato),” for additional benefit and prior authorization criteria.
For more information, call the TMHP Contact Center at 800-925-9126.