Anthem Blue Cross (HMO, PPO, EPO)
Spravato (56 MG Dose) (esketamine)
Drugs for the Nervous System : Drugs for Depression
  • Prior Authorization: Neurogenic Detrusor Overactivity (NDO):
    Documented Diagnosis: Yes
    Age Requirement: >= 3
    Duration: 12 Month(s)
    Reauthorization Required: Yes

  • Step Therapy: ST_APPLIES
  • Quantity Limit: 1 tablet per 1 day(s).
  • Prior Authorization: PA Applies
  • Quantity Limit: limit maximum 1 EA PER 1 day(s)