Kaiser Foundation Health Plan Southern California
Spravato 28 Mg Spry (esketamine)
Drugs for the Nervous System : Drugs for Depression
  • Step Therapy: Diabetic Medical Supplies:
    ST Multiple Brands

  • Step Therapy: COPD (oral):
    Incruse Ellipta and 1 of [Spiriva Respimat, Spiriva With HandiHaler]
  • Neurology: Epilepsy:
    Duration: 1 plan year
    Documented Diagnosis: Yes
    Medical Test Required: No
    Reauthorization Required: Yes
    Duration of Reauthorization: = 1 plan year
    Diagnosis Type(s): 1 of Myoclonic Seizures;Partial-Onset Seizures;Primary Generalized Tonic-Clonic Seizures
    Used as Adjunctive Treatment: No
    Duration of Failure or Adjunctive Treatment with Other Antiepileptic Product: N/A
    Documented history of persisting seizures after titration to highest tolerated dose of each AED.: No
    Lack of compliance as a reason for treatment failure has been ruled out: No
    Documentation of treatment failure due to intolerable side effects.: No
    Supporting Documentation Requirements: 1 of Chart Notes;Medication History
    Positive Response to Therapy Required for Reauth: Yes
    Treatment for Age 17 years or older: No
    Treatment for Age 1-16 years old: No
    History of >= to 30 day trial of other AED required: No
    Reapproval based on response: Yes

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