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Prior Authorization Updates for Esketamine (Spravato) Effective May 1, 2025, for Texas Medicaid

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Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to Medicaid members who are enrolled in their MCO. Administrative procedures, such as prior authorization, precertification, referrals, and claims and encounter data filing, may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the member’s specific MCO for details.

Effective for dates of service on or after May 1, 2025, prior authorization criteria for esketamine (Spravato) will change.

Treatment Indications

Esketamine (Spravato) will also be indicated as monotherapy for adult clients who are 18 years of age or older with treatment-resistant depression.

Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.46, “Esketamine (Spravato),” for additional indications for esketamine (Spravato).

Diagnosis Requirements

The following diagnosis codes for major depressive disorder will also be considered for prior authorization:

Diagnosis Codes
F0631F0632F0634F3289F32AF333F338
F341F530     

Refer to the current Texas Medicaid Provider Procedures Manual, Outpatient Drug Services Handbook, subsection 6.46.1, “Prior Authorization,” for additional diagnosis codes that will be considered for prior authorization.

For more information, call the TMHP Contact Center at 800-925-9126.