Kaiser Foundation Health Plan Northern California
Spravato 28 Mg Spry (esketamine)
Drugs for the Nervous System : Drugs for Depression
  • Step Therapy: Juvenile Idiopathic Arthritis:
    ST Single Generic

  • Quantity Limit: Limit 6 sprayers per month;QL(2 ea daily)
  • Prior Authorization: Diabetic Medical Supplies:
    Documented Diagnosis: Yes
    Duration: 1 plan year
    Reauthorization Required: Yes