How prior authorization works for Spravato

Why there is a prior authorization

Spravato costs a plan roughly ,000 per session and involves 8 sessions in the first month. Almost every commercial and Medicare Advantage plan requires approval before the first dose. Original Medicare does not, but the clinic must still document the same criteria. See the Spravato hub, the coverage hub, the coverage checker, treatment comparisons and condition and treatment pages.

What the clinic submits

1. Diagnosis of major depressive disorder (or MDD with suicidal thoughts).
2. A list of antidepressants tried in the current episode with doses, dates and outcomes. Two adequate trials is the threshold.
3. Confirmation that you are on an oral antidepressant now.
4. A baseline rating scale score (PHQ-9, MADRS or HAM-D).
5. Confirmation that the clinic is REMS certified and that you have no exclusions (uncontrolled hypertension, aneurysm, pregnancy, psychosis).

What happens next

The plan's reviewer compares the submission with the written policy. Approval usually comes in 3 to 10 business days for commercial plans and up to 14 for Medicare Advantage. Approval covers the induction phase (typically 8 sessions over 4 weeks). A reauthorization with an updated score showing improvement is needed for maintenance sessions; plans commonly want a 50 percent improvement, or at least a meaningful drop.

Common denial reasons

• Fewer than two documented adequate trials (the most common by far).
• No oral antidepressant on the current medication list.
• A bipolar diagnosis anywhere in the chart.
• Missing baseline score.
• Trials outside the current episode.

Fixing a denial

1. Read the denial letter for the specific criterion.
2. Ask the clinic to request a peer-to-peer call. The prescriber talks to the plan's medical director; documentation denials are often reversed on the call.
3. If needed, file a written appeal with the missing records. Commercial plans allow 180 days; Medicare Advantage 60.
4. If the internal appeal fails, request an external review by an independent reviewer. It is free and binding.

How to help

Send your pharmacy dispensing history to the clinic before the intake. Nothing shortens the process more. See the Spravato guide and your insurer's page on the coverage hub.