Anthem Blue Cross (HMO, PPO, EPO)
Spravato 28 Mg Spry (esketamine)
Drugs for the Nervous System : Drugs for Depression
  • Step Therapy: Major Depressive Disorder:
    Step Applies
  • Prior Authorization: Major Depressive Disorder:
    PA Applies 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