| Kaiser Foundation Health Plan Southern California |
| Spravato 28 Mg Spry (esketamine) |
| Drugs for the Nervous System : Drugs for Depression |
- Step Therapy: Major Depressive Disorder:
Step Applies
Major Depressive Disorder with Suicidal Ideation :
Step Therapy Applies
- Prior Authorization: Major Depressive Disorder:
PA Applies
Major Depressive Disorder with Suicidal Ideation :
PA Applies
- Major Depressive Disorder:
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
Documented Diagnosis: No
Major Depressive Disorder with Suicidal Ideation :
Documented Diagnosis: No
Medical Test Required: No
Reauthorization Required: No
Duration of Reauthorization: N/A
|