Spravato Prior Authorization: What Insurers Require in California

Spravato (esketamine) almost always requires prior authorization, and approval turns on documentation: proof of treatment-resistant depression, meaning an inadequate response to at least two adequate antidepressant trials, plus confirmation that treatment will be given at a REMS-certified clinic alongside an oral antidepressant. Requests that arrive with that record complete are routinely approved. Requests that arrive without it are routinely denied, regardless of how much the patient needs the treatment.

On this page: What insurers require · The documentation that decides it · Why the REMS clinic requirement matters · How long authorization takes · If the request is denied

What do insurers require for Spravato?

Plans differ in wording but converge on the same core criteria: a diagnosis of major depressive disorder with an inadequate response to at least two different antidepressants, taken at adequate dose and duration in the current episode; administration under medical supervision at a REMS-certified site; and use together with an oral antidepressant, which is how Spravato is FDA-approved. Some plans also ask about therapy history or require the prescriber to be a psychiatric specialist. Plan-by-plan detail is in our coverage guides for Aetna, Cigna, UnitedHealthcare, Medi-Cal, and Medicare.

The documentation that decides it

Reviewers approve records, not stories. A complete request contains: each antidepressant tried in the current episode with drug name, dose, start and stop dates, and outcome; standardized symptom scores such as the PHQ-9; the diagnosis with duration; and a statement of the oral antidepressant that will accompany treatment. The most common gap is medication history scattered across former prescribers. Gathering it before submission is the single highest-value step, and it is work your clinic should do with you, not assign to you.

Why the REMS clinic requirement matters

Spravato is dispensed and administered only at certified clinics under the FDA’s REMS safety program, with two hours of in-office monitoring after each dose. Insurers verify the site’s certification as part of authorization, so a request from a non-certified setting fails regardless of the clinical record. Exxceed Wellness is a REMS-certified Spravato site; how treatment works here.

How long does authorization take?

With complete documentation, standard determinations commonly come back within days to two weeks, and California law provides for expedited review when a delay would seriously threaten your health. The clock only runs fairly on a complete submission: incomplete requests bounce back with information demands that restart the wait.

If the request is denied

Denials are usually documentation findings, not final judgments. The appeal path is the same one used for TMS: an internal grievance with the plan, then a free, binding Independent Medical Review through the state for most commercial plans. Our guide to appealing a treatment denial in California walks through both steps. Candidacy questions start earlier though: whether Spravato fits your history is worth establishing before any paperwork is filed.

Plan-specific: does Anthem Blue Cross cover Spravato in California?

This article is educational and is not legal or personalized medical advice. Coverage criteria vary by plan and change over time. Reviewed by Nefretiri Abat, PMHNP-BC, JD.