SPRAVATO · CROSS-PAYER DRIFT
FDA-label vs. payer-imposed restrictions for esketamine across 8 commercial/MA payers plus TX/NY Medicaid. 17 criteria dimensions; step-therapy shape is the single most divergent.
10 PAYERS
17 DIMENSIONS
FDA-LABEL ANCHOR
Step-therapy is the single highest-variance dimension. Payer requirements span from "documented TRD diagnosis is sufficient" (CarePartners CT) through 2 same-class → 2 different-class → 2 + augmentation → 3 across ≥2 classes (Premera option A). Aetna additionally pegs trials to "maximized doses for ≥8 weeks within past 5 years" — a temporal-recency restriction no other payer imposes.
Premera is the structural outlier. Only payer with dual-pathway step therapy (3-trial OR 2+augment), only payer that excludes any past/present bipolar diagnosis, only payer that bars current or past psychosis, and the most restrictive SUD posture in the corpus (complete abstinence ≥3 months OR ≥1 month + abstinence agreement OR 24/7 confinement).
Blue Shield CA publishes numeric remission thresholds. Unique in the corpus — MADRS ≤12, HAMD17 ≤7, QIDS-C16 ≤5, PHQ-9 <5. Every other payer uses a qualitative "documented response / improvement from baseline" formulation. This makes BSCA appeals quantitatively defensible and creates a sharp documentation requirement.
FDA-label deviations. The FDA TRD definition is ≥2 antidepressants of adequate dose/duration in the current episode, with monotherapy explicitly allowed since the January 2025 label update. Payers exceeding the label: Aetna (mandatory augmentation), Premera (3 trials or augmentation; abstinence; bipolar/psychosis exclusion), Blue Shield CA (different-class requirement post-5/1/2026, baseline-score gate), Louisiana Blue (8-week minimum per trial, ≥2 classes). Cigna explicitly cites VA/DoD 2022 as rationale for positioning Spravato later than the FDA label allows.
- Most restrictive step therapy: Premera (3 trials or 2+augment) and Aetna (2+augment, 5-year window).
- Most permissive step therapy: CarePartners CT (diagnosis sufficient) and the Cigna/UHC "implied" formulations.
- Most restrictive SUD: Premera (complete abstinence).
- Most restrictive diagnostic exclusions: Premera (bipolar + psychosis).
- Broadest prescriber: CarePartners CT (NP-BH accepted).
- Most quantitatively defined response: Blue Shield CA (numeric remission cutoffs).
Silence is a finding. CHPW, Louisiana Blue, CarePartners CT, and UHC are silent on bipolar/psychosis and (mostly) SUD. In adjudication that flexibility favors appeal; the corpus tags silence explicitly rather than coding it as "no restriction".