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Does Blue Cross Blue Shield Cover Spravato Treatment?

Does Blue Cross Blue Shield Cover Spravato Treatment?

Does Blue Cross Blue Shield Cover Spravato (Esketamine) Treatments?

Blue Cross Blue Shield (BCBS) insurance may cover Spravato (Esketamine) depending on your specific health plan and diagnosis status. BCBS esketamine nasal spray coverage requires certain criteria to be met before insuring this drug.1 Spravato BCBS coverage varies by state and insurance provider. The following are example of approval requirements from the Blue Cross Blue Shield Federal Employee Program:

  • 18 years of age or older
  • Have at least one of the following:
    • Treatment-resistant depression which includes an inadequate treatment response to at least two different types of antidepressants.
    • Major depressive disorder (MDD) with acute suicidal ideation or behavior
  • And have all of the following:
    • Depression that was diagnosed with an approved scoring tool like the PHQ-9
    • Is used in conjunction with an oral antidepressant
    • Is administered under the supervision of a healthcare provider
    • Blood pressure is to be assessed prior and after each administration
    • Prescriber agrees to monitor for sedation and dissociation for at least two hours after administration
    • Healthcare setting, pharmacy, and patient are registered with the The Risk Evaluation and Mitigation Strategy (REMS) program
    • Prescriber agrees to monitor for clinical worsening and emergence of suicidal thoughts and behaviors
    • Prescriber agrees to advise pregnant females and females of reproductive potential about the risks for fetal harm

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How to Verify BCBS Coverage for Spravato

Athena Care and its Spravato treatment clinics in Tennessee are in-network with most major insurance plans. Filling out our free and confidential online insurance verification form is the best method to determine your BCBS Spravato coverage in Tennessee.

Allow our highly skilled care coordinators to handle the hassles of contacting your insurance company for more information about BCBS Spravato benefits. A care coordinator will review your insurance and thoroughly explain your options after you’ve submitted the form. Rest assured that all information shared or discussed is kept confidential.

What is Spravato?

Spravato, also known as esketamine, is the brand name of a prescription nasal spray medication that the (Food and Drug Administration) FDA approved in March of 2019. Esketamine is a new type of ketamine, an anesthetic that was extensively used as a veterinary medication or on battlefields, that can be taken intranasally and provides quick and effective benefits.2

Spravato is used with an antidepressant to treat individuals with treatment-resistant depression (TRD) and adults with major depressive disorder (MDD).3 TRD encompasses patients with MDD with acute suicide ideation or behaviors who have not responded to at least two antidepressant medications administered at acceptable doses for an adequate time.4

The effect rate varies by research, but randomized trials have shown that Spravato can relieve TRD quickly. Depending on the length of treatment with Spravato, studies suggest 40-60% efficacy.5

Three four-week clinical trials and one longer-term maintenance-of-effect trial were used to assess Spravato’s efficacy. Patients were randomly assigned to receive Spravato or a placebo nasal spray in the three short-term experiments. Because of the serious nature of TRD and the requirement for patients to get therapy, all of the patients started a new oral antidepressant at the same time and continued it throughout the trials.

Spravato had a statistically significant effect on the severity of depression in one of the short-term studies, and some were apparent within two days. However, the two other short-term trials failed to pass the statistical tests required to demonstrate effectiveness.

Patients in stable remission who continued to receive Spravato alongside an oral antidepressant had a significantly longer time before relapsing with depressive symptoms than patients on placebo nasal spray plus in the longer-term maintenance-of-effect trial.

Risks & Side Effects of Spravato

The most common side effects patients treated with Spravato experienced in clinical trials included:

  • Disassociation
  • Dizziness
  • Nausea
  • Drowsiness
  • Vertigo
  • Decreased feeling or sensitivity (hypoesthesia)
  • Anxiety
  • Lethargy
  • Elevated blood pressure
  • Vomiting
  • Feeling inebriated

Esketamine comes with boxed warnings about the danger of drowsiness and dissociation and the potential for abuse and misuse. There is also potential for an elevated risk of suicidal thoughts and behaviors in children and young adults.6 For this reason, Spravato is not approved for use in children. In addition, patients with uncontrolled or poorly managed hypertension or pre-existing aneurysmal vascular diseases may be more susceptible to complications.

Furthermore, Spravato may compromise attention, judgment, reasoning, response time, and motor skills. Patients shouldn’t drive or operate machinery until the next day after receiving the drug. Spravato also has the potential to harm a fetus; thus, women who are pregnant or want to get pregnant should take precautions. Women should not breastfeed while being treated.

These side effects could persist anywhere from a few days to weeks. Consult your doctor if the adverse effects persist, concern you, or become severe.7 Keep in mind that the oral antidepressant and not Spravato could cause some side effects.

Spravato can only be administered in a licensed healthcare setting with medical professionals trained to prescribe and distribute it.8 The Risk Evaluation and Mitigation Strategy (REMS) program for Spravato mandates that healthcare facilities that administer the medicine be certified.9 Therefore, Spravato is not available at your local pharmacy.

The Food and Drug Administration (FDA) launched the REMS program to lower the dangers of giving certain medications with severe adverse effects. REMS programs assist customers in medication management. In addition, they instruct healthcare providers on how to closely monitor and prescribe these medications.10 This allows Spravato doctors to determine whether the drug’s benefit outweighs its danger.

How Much Does Spravato Cost Without Insurance?

Without BCBS Spravato coverage, the following are average costs for the medication. These costs will differ by location and other variables. They may not reflect the actual cost of what you’ll pay for Spravato treatment in Tennessee.

Spravato will most likely cost more at the beginning of treatment and less in the long run. Depending on whether dosing is weekly or bi-weekly, costs can range from $5,664 to $8,142 in the first month of treatment, $2,832 to $4,248 in the second month, and possibly $1,416 to $4,248 each month after.

Sources

  1. Blue Cross Blue Shield Federal Employee Program. “Spravato (esketamine nasal spray).” 1 Oct. 2021, https://www.fepblue.org/-/media/PDFs/Medical%20Policies/11-16-2021/Pharma%20Policies%20Replace/56033%20Spravato%20esketamine%20nasal%20spray.pdf
  2. Bruno, Bryan Medical Director. “The Difference Between Ketamine and Esketamine (Spravato) for Depression Treatment.” Mid City TMS, Mid City TMS, 15 Apr. 2021, www.midcitytms.com/the-difference-between-ketamine-and-esketamine-spravato-for-depression-treatment
  3. “SPRAVATO® (Esketamine) | SPRAVATO®.” SPRAVATO® (Esketamine), Janssen Pharmaceuticals, Inc., 23 Feb. 2022, www.spravato.com/trd
  4. Office of the Commissioner. “FDA Approves New Nasal Spray Medication for Treatment-Resistant Depression; Available Only at a Certified Doctor’s Office or Clinic.” U.S. Food and Drug Administration, U.S. Food and Drug Administration, 6 Mar. 2019, www.fda.gov/news-events/press-announcements/fda-approves-new-nasal-spray-medication-treatment-resistant-depression-available-only-certified
  5. Anca. “What Is the Success Rate of Spravato for Treatment-Resistant Depression?” Ketamine Clinic of Pennsylvania, Ketamine Clinic of Pennsylvania, 8 July 2019, kcofp.com/ufaqs/what-is-the-success-rate-of-spravato-for-treatment-resistant-depression
  6. Bahr, Rebecca et al. “Intranasal Esketamine (SpravatoTM) for Use in Treatment-Resistant Depression In Conjunction With an Oral Antidepressant.” P & T : a peer-reviewed journal for formulary management vol. 44,6 (2019): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6534172/
  7. Seabright, Jen PharmD. “Spravato Side Effects: What You Should Know.” Medical News Today, Healthline Media UK Ltd, 21 Mar. 2022, www.medicalnewstoday.com/articles/drugs-spravato-side-effects#fa-qs
  8. “What Are the Success Rates of Esketamine?” Mindful Health Solutions, Mindful Health Solutions, 22 Feb. 2022, mindfulhealthsolutions.com/treatment-faqs/esketamine/what-are-the-success-rates-of-esketamine
  9. Center for Drug Evaluation and Research. “Risk Evaluation and Mitigation Strategies | REMS.” U.S. Food and Drug Administration, U.S. Food and Drug Administration, 17 Dec. 2021, www.fda.gov/drugs/drug-safety-and-availability/risk-evaluation-and-mitigation-strategies-rems
  10. Slowiczek, Lindsay PharmD. “Spravato (Esketamine).” Medical News Today, Healthline Media UK Ltd, 11 Dec. 2021, www.medicalnewstoday.com/articles/326038#_noHeaderPrefixedContent

If you suspect that you or someone you love suffers from mental health disorders, contact Athena Care today.

One of our friendly associates will help you get the help you need. Take this first step to feel better and take control. 

(615) 320-1155