| Anthem Blue Cross (HMO, PPO, EPO) |
| Spravato (56 MG Dose) (esketamine) |
| Drugs for the Nervous System : Drugs for Depression |
- Step Therapy Applies
- Prior Authorization: Major Depressive Disorder with Suicidal Ideation :
Documented Diagnosis: Yes
Age Requirement: >= 18
Duration: 4 week(s)
- Major Depressive Disorder:
Age Requirement: >= 18
Duration: 3 Month(s)
Medical Test Required: No
Reauthorization Required: Yes
Duration of Reauthorization: = 12 month(s)
Documented Diagnosis: Yes
Major Depressive Disorder with Suicidal Ideation :
Age Requirement: >= 18
Duration: 4 week(s)
Documented Diagnosis: Yes
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
- Quantity Limit: 4 kits per 28 day(s).
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