Does S0013 require prior authorization?

No, S0013 does not require prior authorization (high confidence). Covered without prior authorization.

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`S0013`, Esketamine, nasal spray, 1 mg

HCPCS/CPT

Prior Authorization

No Prior Auth Required

Covered without prior authorization (high confidence)

Documentation Required

Enroll all treated individuals in the REMS registry to characterize risks and support safe use.
Evaluate therapeutic benefit at the end of the induction phase to decide on continuation of treatment.
Pharmacies and healthcare settings that dispense esketamine must be certified.
Ensure each individual is informed about risks of sedation/dissociation and the need for monitoring.

Key Coverage Criteria

Treatment-resistant depression: induction weeks 1-4 — twice weekly dosing (day 1 start 56 mg; subsequent doses 56 mg or 84 mg); maintenance weeks 5-8 — once weekly (56 mg or 84 mg); from week 9 onward — every 2 weeks or once weekly (56 mg or 84 mg); individualize to the least frequent dosing to maintain remission/response.
Major depressive disorder with acute suicidal ideation or behavior: 84 mg twice weekly for 4 weeks (may reduce to 56 mg twice weekly for tolerability); use beyond 4 weeks has not been systematically evaluated.
Treatment-resistant depression: induction weeks 1-4 — twice weekly dosing (day 1 start 56 mg; subsequent doses 56 mg or 84 mg); maintenance weeks 5-8 — once weekly (56 mg or 84 mg); from week 9 onward — every 2 weeks or once weekly (56 mg or 84 mg); individualize to the least frequent dosing to maintain remission/response.
Major depressive disorder with acute suicidal ideation or behavior: 84 mg twice weekly for 4 weeks (may reduce to 56 mg twice weekly for tolerability); use beyond 4 weeks has not been systematically evaluated.
Treatment-resistant depression: induction weeks 1-4 — twice weekly dosing (day 1 start 56 mg; subsequent doses 56 mg or 84 mg); maintenance weeks 5-8 — once weekly (56 mg or 84 mg); from week 9 onward — every 2 weeks or once weekly (56 mg or 84 mg); individualize to the least frequent dosing to maintain remission/response.
Major depressive disorder with acute suicidal ideation or behavior: 84 mg twice weekly for 4 weeks (may reduce to 56 mg twice weekly for tolerability); use beyond 4 weeks has not been systematically evaluated.

4 Active Policies

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BCBSOK-RX501.105, Esketamine Nasal Spray

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S0013, Esketamine, nasal spray, 1 mg