Does Your Insurance Company Cover Spravato (Esketamine) for Depression?

These criteria summarize how HCSC Blue Cross and Blue Shield plans decide whether Spravato is medically necessary. Your clinic reviews them with you and confirms details during your evaluation before asking HCSC to cover treatment.

• Age 18 or older with major depressive disorder diagnosed as moderate to severe and seriously affecting daily functioning.
• Current episode meets HCSC’s definition of treatment-resistant depression after at least two antidepressants from different types at right doses.
• Each antidepressant was taken at the right dose for six to eight weeks unless stopped early for serious side effects.
• For some plans, at least one add-on medication or structured psychotherapy was tried and still left significant depressive symptoms.
• Spravato is used with an ongoing oral antidepressant, not alone, and only in a certified REMS Spravato treatment center.
• You do not have untreated substance misuse, active psychosis, or serious blood-vessel problems that make Spravato unsafe.
• Prescriber is a psychiatrist or mental-health specialist who supervises dosing on site and monitors you for two hours.

Your clinic handles every step of the Spravato approval process with HCSC after your evaluation confirms you meet the medical rules. You do not fill out these request forms yourself; the clinic submits them on your behalf.

1. They list all antidepressants you tried with names, doses, dates, and whether they failed from side effects or poor benefit.
2. They attach depression rating-scale scores, clinic notes, and hospital records showing how severe your symptoms are despite treatment.
3. They document your main diagnosis, any suicidal thoughts or attempts, and why Spravato is needed now instead of more changes.
4. They confirm you receive Spravato only in a certified clinic with blood-pressure checks, observation, and a safe ride home.
5. They submit HCSC’s request form or portal entry with records and respond to any follow-up questions from reviewers.
6. They tell you when a decision arrives, review the approval details, and help appeal if HCSC first denies the request.

HCSC Blue Cross and Blue Shield plans cover Spravato as a medical benefit, not a simple pharmacy pickup. Your share of the bill depends on your deductible, coinsurance, network, and whether you receive care in a hospital or clinic.

• Spravato is billed as a medical-benefit specialty drug plus clinic services, not a simple pharmacy prescription you pick up.
• You may pay a percentage of each visit cost after meeting your deductible, often between 10 percent and 40 percent.
• Deductible and coinsurance usually apply to both the Spravato drug charge and the monitoring time billed by the clinic.
• After you reach your yearly out-of-pocket maximum, HCSC generally pays covered Spravato costs for the rest of the year.
• Facility fees can differ widely between hospital-based programs and independent clinics, so your clinic’s benefits check is crucial.
• Use my Spravato insurance cost calculator to estimate your share based on deductible, out-of-pocket limit, and coinsurance rate.

Most Spravato coverage questions are easiest to handle through your clinic and the member portal listed on your card in my experience. If you want to call HCSC Blue Cross and Blue Shield yourself, these numbers and links can help you start. Have your member ID, group number, recent Spravato explanation-of-benefits letters, or portal screenshots nearby before you call.

• BCBSIL individual and Marketplace member services: 1-800-538-8833, often printed on Illinois Blue Cross and Blue Shield cards.
• BCBSTX individual member services: 1-888-697-0683; use the number on your card if it differs for your group.
• Deaf or hard-of-hearing members can call TTY 711 and ask to be connected to their state HCSC Blue plan.
• Use the HCSC Blue Cross and Blue Shield member portal to check benefits, claims, and prior approvals online any time.
• For more options, visit your local Blue Cross and Blue Shield contact and support page from your plan’s website or start at HCSC’s contact and support options.

These references show where HCSC documents Spravato and Esketamine Nasal Spray in its own medical-policy system. Your clinic relies on this material, together with your plan documents, when they request coverage on your behalf. Checking the date and policy numbers helps you and your clinic confirm you are looking at the most current criteria.

• Policy name: Mental Health Services (PSY301.000) with related drug policy RX501.105 Esketamine Nasal Spray.
• Document number: PSY301.000; Esketamine Nasal Spray is referenced as RX501.105 in the coding and related-policy section.
• Effective date: current online version labeled 2024-12-15; always rely on the date printed in the linked PDF.
• Applies to: many commercial HCSC Blue Cross and Blue Shield plans in Illinois, Texas, New Mexico, Oklahoma, and Montana.
• View the complete policy at HCSC’s official policy, which also points to the Esketamine Nasal Spray medical policy RX501.105.
• For exact step-therapy and renewal rules, your clinic uses the detailed policy text and your benefit booklet, not this summary.

This is for understanding only. Your clinic verifies you meet these criteria during your evaluation.

• Age requirement: You must be 18 years or older.
• Diagnosis: Treatment-resistant major depressive disorder confirmed by a mental health professional, or major depressive disorder with acute suicidal ideation or behavior.
• Failed medications: You tried at least three different antidepressants from at least two different drug classes (like SSRIs, SNRIs, tricyclics, bupropion, or mirtazapine).
• Treatment duration: Each medication was used at the right dose for at least 8 weeks during your current depression episode.
• Proof it didn’t work: Your medical records include at least one depression rating scale showing symptoms (PHQ-9, MADRS, HAM-D, or QIDS-SR-16).
• Concurrent treatment: Spravato will begin at the same time as a new oral antidepressant medication.
• Prescriber requirement: Treatment must be prescribed by a psychiatrist or in consultation with one.
• Setting requirement: The clinic must be certified in the Spravato REMS program.

Your clinic’s insurance team handles this entire process after your evaluation. This shows you what they’re doing on your behalf with UnitedHealthcare.

1. List of three failed antidepressants with specific drug names, doses, and how long you took each one (at least 8 weeks each).
2. Depression rating scale scores from at least one assessment tool (PHQ-9, MADRS, HAM-D, or QIDS-SR-16).
3. Documentation that you have treatment-resistant depression diagnosed by a mental health professional.
4. Confirmation that treatment is prescribed by a psychiatrist or in consultation with one.
5. Documentation that you’ll start a new oral antidepressant at the same time as Spravato treatment begins.
6. Confirmation that the clinic is certified in the Spravato REMS program for safe administration.

• Spravato is typically covered under UnitedHealthcare’s pharmacy benefit as a specialty medication requiring prior authorization.
• Specialty tier coinsurance: Most plans charge 25-33% coinsurance for specialty medications after you meet your deductible.
• Your deductible applies first – you pay full cost until you meet your annual deductible.
• After deductible, you pay your coinsurance percentage until you reach your out-of-pocket maximum.
• Treatment schedule: Twice weekly for 4 weeks, then weekly for 4 weeks, then every other week or weekly for maintenance.
• Facility and monitoring costs may apply separately for the 2-hour observation period required after each dose.
• Use my Spravato insurance cost calculator to get a personalized estimate based on your specific plan details.

• Member Services: Call the phone number on your member ID card (available 24 hours a day, 7 days a week for most plans)
• General Member Services: 1-866-414-1959
• TTY for hearing impaired: 711
• Access your UnitedHealthcare member portal to check your benefits and coverage details.
• Visit UnitedHealthcare contact and support options for additional help and resources.

• Policy name: Spravato (esketamine) – Prior Authorization/Medical Necessity.
• Program number: 2025 P 2168-10.
• Effective date: May 1, 2025 (P&T approval dates: 6/2019, 9/2019, 2/2020, 12/2020, 4/2021, 4/2022, 12/2022, 12/2023, 6/2024, 3/2025).
• Approval duration: Initial approval typically for 12 months for treatment-resistant depression.
• Applies to: UnitedHealthcare commercial pharmacy plans.
• View the complete policy at UnitedHealthcare’s official Spravato coverage policy.

This section unpacks how Anthem Blue Cross Blue Shield applies its Spravato rules so you understand what your clinic is checking.

Your psychiatrist and clinic staff match your history to Anthem’s criteria during the evaluation; you never have to memorize this list yourself.

• Age eighteen or older with major depressive disorder that is moderate to severe, not a mild or short-lived episode.
• Current episode meets Anthem’s definition of treatment-resistant depression based on standard depression rating scales and clinical judgment.
• At least two antidepressants from different types were taken at the right dose long enough without enough symptom relief.
• Each failed medication trial is backed by chart notes describing dose, duration, side effects, and how much you improved.
• Spravato will always be paired with an oral antidepressant, not used by itself or combined with IV ketamine treatments.
• Your depression does not include uncontrolled psychosis, and any substance use issues are being actively managed and monitored.
• Anthem excludes people with certain serious blood vessel problems, brain bleeding, or severe liver disease because of safety concerns.

After your Spravato evaluation, the clinic’s insurance team gathers detailed paperwork so Anthem can decide whether to approve treatment.

You do not fill out PA forms yourself; your clinic submits everything electronically or by fax and tracks the response.

1. Medication history listing each failed antidepressant with drug names, maximum doses, trial dates, and reasons each one was stopped.
2. Depression rating scale scores before and after medication trials to show limited improvement despite right-dose, long-enough treatment attempts.
3. Current diagnosis details, including whether you meet criteria for treatment-resistant depression or major depression with acute suicidal symptoms.
4. Notes from your psychiatric evaluation describing symptom severity, safety concerns, and why Spravato plus an antidepressant is being recommended.
5. Attestations that treatment will occur in a certified Spravato center with monitoring, transportation home, and no at-home self-administration.
6. Screening for substance use, psychosis, uncontrolled blood pressure, and other conditions that could make Spravato unsafe or require extra monitoring.
7. Anthem Esketamine (Spravato) Request Form or similar PA template, completed and signed by your treating psychiatrist or clinic prescriber.

Anthem pays most of the Spravato cost, but your share depends on how your plan handles medical visits, deductibles, and coinsurance.

Your clinic checks your specific benefits with Anthem before starting treatment and can show you a written estimate based on your plan.

• Spravato is billed as a medical benefit using bundled visit codes that cover the drug and two hours of monitoring.
• Some plans separate drug and facility charges, putting Spravato on a specialty tier and the visit under outpatient services.
• Your deductible may apply first, so you pay the full allowed amount until you meet that yearly threshold.
• After the deductible, coinsurance means you pay a percentage of each visit’s allowed charge until you hit your out-of-pocket maximum.
• Facility fees, observation time, and required monitoring are included in the visit charge, not separate surprise bills from Spravato.
• Use my Spravato insurance cost calculator to get a personalized estimate based on your deductible, out-of-pocket maximum, and coinsurance rate.
• The Spravato schedule starts with frequent visits, then shifts to weekly or every-other-week sessions during maintenance treatment.
• Check Spravato’s tier and any extra limits using Anthem’s online drug list search tool for your state.

Most Anthem Blue Cross Blue Shield cards list plan-specific phone numbers, which should be your first call for Spravato benefit questions.

If you do not have your card handy, these general resources can help you reach Anthem and review your coverage details.

• Member Services: call the number printed on your Anthem or Anthem Blue Cross Blue Shield ID card for plan-specific questions.
• General assistance line: 800-331-1476 for many Anthem Blue Cross members, with representatives available Monday through Friday business hours.
• TTY users can dial 711 and ask to be connected to Anthem Member Services for help reviewing mental health benefits.
• Use the Anthem member portal to view benefits, check claims, download ID cards, and send secure messages about Spravato coverage.
• Go to Anthem’s main contact page for links to state-specific phone numbers, live chat, and other support options.
• Many plans support the Sydney Health app, which lets you chat with Anthem, view benefits, and access ID cards.

Anthem publishes Spravato rules in its Medical Drug Clinical Criteria library, which guides how plans decide whether to pay for treatment.

Knowing which document your clinic uses can help you feel confident that their answers about coverage come straight from Anthem’s internal playbook.

• Policy name: Medical Drug Clinical Criteria for Spravato (esketamine) Nasal Spray.
• Document ID: CC-0086, listed under Spravato on Anthem’s clinical criteria index with associated billing codes.
• Effective date: December 18, 2023 publish update, with earlier review history noted in the document history section.
• Applies to many Anthem commercial and some affiliated plans; self-funded or carve-out arrangements may follow separate coverage rules.
• Policy outlines dosing schedule that mirrors the FDA label, including induction and maintenance phases with specified treatment frequencies.
• View the complete policy at Anthem’s official Spravato coverage policy used by clinics for coverage review and approval decisions.
• Clinics may also use an Anthem Esketamine (Spravato) Request Form, which mirrors these criteria and collects required clinical details.

These points summarize how Aetna decides whether Spravato is medically necessary; your clinic compares your history against them during evaluation.

Some people qualify because medicines failed, while others qualify because of dangerous suicidal symptoms in the current depressive episode.

You never submit this checklist to Aetna yourself; your psychiatrist documents everything in chart notes and standardized depression scores.

• You have major depressive disorder that is severe and long-lasting, not a brief low spell or mild mood change.
• You are 18 or older and treatment happens in an outpatient clinic, never at home or in a pharmacy booth.
• You tried at least two antidepressants from different types at high enough doses for about eight weeks each.
• Depression rating scales before and after those medicines show too little improvement despite sticking with treatment as directed.
• You also tried an add-on medication strategy or structured therapy, with proof it did not improve symptoms enough.
• Spravato will be given with an oral antidepressant, not alone or combined with IV ketamine infusions for depression.
• Aetna excludes people with severe alcohol or drug use disorder unless it is actively treated or medically managed.

After your Spravato evaluation, the clinic’s staff prepares a detailed request so Aetna can decide whether to approve treatment.

They send this through Aetna’s prior authorization system, using drug policy forms that match Clinical Policy Bulletin 0950 and SGM 2889.

1. List of past antidepressants, including names, maximum doses, dates, and notes showing each one failed to help enough.
2. Standard depression rating scale scores from before and after those medicines, proving serious symptoms remain despite sticking with treatment.
3. Documentation of any add-on medications or structured talk therapy you tried, with proof those approaches did not work well enough.
4. Current depression severity scores and clinical notes describing suicidal symptoms if they are part of why Spravato is requested.
5. Confirmation that Spravato will be given in a certified clinic with two hours of monitoring and safe transportation home.
6. Attestation that you do not have untreated severe alcohol or drug use disorder and that key medical problems are controlled.
7. A completed Aetna Spravato Medication Precertification Request form or equivalent pharmacy request form signed by your psychiatrist.

Aetna pays most of the Spravato cost once coverage is approved, but your share depends on how your specific plan is structured.

Your Spravato clinic runs a benefits check with Aetna before treatment and can give you a written estimate for early visits.

• Many plans treat Spravato as a medical benefit, bundling the drug, observation time, and clinic charges into one visit code.
• Some plans also apply pharmacy rules for Spravato; check Aetna’s online formulary search tool to see tier and restrictions.
• Your annual deductible may apply first, meaning you pay the allowed amount until that deductible is fully met.
• After the deductible, many plans charge a percentage of each visit until you reach your yearly out-of-pocket maximum.
• The Spravato schedule starts with twice-weekly visits, then weekly, then every one to two weeks during maintenance.
• Use my Spravato insurance cost calculator to estimate your share based on your deductible, coinsurance rate, and out-of-pocket maximum.

Your Aetna ID card is the best source for plan-specific phone numbers, which you should use first for Spravato questions.

If you cannot find the card, these general contacts help you reach Member Services and review your mental health benefits. They may not see your full claims history but can route you to the right place.

• Call the Member Services number printed on your Aetna ID card for questions about Spravato coverage and costs.
• For general questions, call Aetna’s corporate contact center at 1-800-US-AETNA (1-800-872-3862).
• TTY users can dial 711 and ask to be connected to Aetna Member Services for help reviewing benefits.
• For pharmacy questions, many plans use 1-888-792-3862, which can route you to people who handle drug coverage questions.
• Use the Aetna secure member account portal to view benefits, check claims, and see which services are covered.
• Visit Aetna’s contact and support options page for plan-specific phone numbers, mailing addresses, and online tools.

This snapshot helps you and your clinic match what you are experiencing with Aetna’s written rules for Spravato coverage.

It also explains why clinics may ask detailed questions about past medications, therapy, and rating scales before requesting approval.

The clinic relies on these documents when they request approval, but you only need the highlights listed here.

• Policy name: Esketamine (Spravato) — Medical Clinical Policy Bulletin Number 0950 for commercial medical plans.
• Related pharmacy policy: Spravato SGM 2889-A P2024a_R for Aetna non-Medicare prescription drug plans.
• Last reviewed: policy cites the 2025 Spravato label and references accessed on October 21, 2024.
• Applies to: many commercial Aetna plans; Medicare and Medicaid lines have their own criteria and procedures.
• Key coverage focus: adults with treatment-resistant depression or major depression with acute suicidal symptoms who meet safety rules.
• View the complete policy at Aetna’s official Spravato coverage policy; clinics also use Aetna’s Medical Exception/Prior Authorization/Precertification Request for Prescription Medications form for pharmacy requests.

This list translates Florida Blue’s medical policy into plain language; your Spravato clinic confirms every detail during your evaluation and before requesting approval.

• Age 18 or older with major depressive disorder and a current moderate-to-severe depressive episode.
• Either treatment-resistant depression despite multiple medications, or major depression with acute suicidal thoughts or a recent suicidal crisis.
• Depression rating scale shows severe symptoms on PHQ-9, MADRS, QIDS-C16, or HAMD-17 while still taking antidepressant medication.
• In this episode, you tried at least two antidepressants from different types at the right dose for six weeks each.
• At least one antidepressant was used with an add-on medication like an atypical antipsychotic, lithium, buspirone, or thyroid hormone.
• No aneurysm, arteriovenous malformation, brain bleed, or severe liver disease, and you are not pregnant or trying to conceive.
• Spravato is given only in a certified REMS clinic under direct medical supervision with on-site blood pressure and safety monitoring.

Your Spravato clinic handles the entire insurance approval process after your evaluation; here is the kind of information they send Florida Blue on your behalf. You do not gather these records; the clinic assembles and submits them for you.

1. List of every antidepressant you tried this episode, with names, doses, schedules, and how long you stayed on each.
2. Details on any add-on medications, such as atypical antipsychotics, lithium, buspirone, or thyroid hormone, used with your antidepressants.
3. Depression rating scale scores showing severe symptoms before Spravato and change over time if treatment is continued.
4. Clinical notes confirming your diagnosis, current severity, and whether you have treatment-resistant depression or depression with acute suicidal thoughts.
5. Safety screening information, including heart and blood vessel history, liver function, pregnancy status, and any serious substance use issues.
6. Confirmation that a psychiatrist directs your care and that Spravato is given in a certified REMS clinic with on-site monitoring.

Spravato is costly, but Florida Blue applies your usual deductibles, copays, and coinsurance; your clinic can estimate charges before you start treatment. Most people want to know the worst-case bill before starting, and clinics can model that with your plan.

• Spravato is treated as a specialty drug billed through your medical or pharmacy benefit, depending on your Florida Blue plan.
• You may owe percentage coinsurance instead of a flat copay, and many plans require you to meet your deductible first.
• Each visit usually includes the Spravato drug charge plus clinic, monitoring, and observation fees billed as outpatient facility services.
• Spravato charges count toward your yearly out-of-pocket maximum; after you reach it, Florida Blue pays covered costs for the year.
• Use my Spravato insurance cost calculator to estimate your costs using your deductible, coinsurance, and out-of-pocket maximum amounts.
• You and your clinic can confirm Spravato’s tier and limits in Florida Blue’s Open Medication Guide or your plan’s formulary.

If you want to confirm what a clinic tells you, you can contact Florida Blue directly or use their online tools securely. These options help you double-check Spravato coverage, copays, and limits before you begin Spravato treatment with them.

• Member Services for most individual and employer plans: 800-352-2583, Monday through Friday, 8 a.m. to 6 p.m. Eastern Time.
• TTY/TDD for commercial members with hearing or speech difficulties: 800-955-8771 for relay assistance.
• Florida Blue Medicare Member Services: 800-926-6565 (TTY 800-955-8770), with detailed hours listed on the Medicare website and your ID card.
• Log in to the Florida Blue member portal to check Spravato benefits, see claims, and review deductibles and out-of-pocket totals.
• Visit Florida Blue’s Getting Help page for chat, local Florida Blue Center locations, and additional contact and support options.
• Your member ID card may show different phone numbers; use those instead of any general numbers listed here when unsure.

This snapshot summarizes Florida Blue’s official Spravato medical coverage guideline; your exact benefits still depend on your specific contract and any program exceptions. The information below helps you match what your clinic says to the wording in that document.

• Policy name: Esketamine (Spravato) Nasal Spray — Medical Coverage Guideline for outpatient use.
• Document ID: 09-J3000-37, used by Florida Blue to reference this Spravato guideline in internal systems and tools.
• Most recently revised November 15, 2025; original effective date June 15, 2019.
• Applies to most Florida Blue commercial and Medicare Advantage products unless a program exception section lists a different rule.
• Parent company: GuideWell; branded to members as Florida Blue, an independent licensee of the Blue Cross Blue Shield Association.
• View the complete policy at Florida Blue’s official Spravato coverage policy.
• Coverage is considered medically necessary when all listed criteria are met, including diagnosis, failed medications, severity scores, and safety exclusions.

This is for understanding only. Your clinic verifies you meet these criteria during your evaluation.

• Age requirement: You must be 18 years or older.
• Diagnosis: Treatment-resistant depression confirmed by a psychiatrist.
• Failed medications: You tried at least two different antidepressants from different drug classes (like SSRIs, SNRIs, tricyclics, bupropion, or mirtazapine).
• Treatment duration: Each medication was used at the right dose for at least 6 weeks during your current depression episode.
• Proof it didn’t work: Each medication showed 25% improvement or less in your depression symptoms or scores.
• Psychosis history: Either you have no history of psychosis, or your psychiatrist believes Spravato’s benefits outweigh risks despite psychosis history.
• Safety check: Your psychiatrist checked your state’s prescription drug monitoring program for your controlled substance history.
• Prescriber requirement: Treatment must be prescribed by a psychiatrist who specializes in depression.

Your clinic’s insurance team handles this entire process after your evaluation. This shows you what they’re doing on your behalf with Cigna.

1. List of failed antidepressants with specific drug names, doses, and how long you took each one (at least 6 weeks each).
2. Depression severity scores proving the medications didn’t work (showing 25% improvement or less).
3. Documentation that you have treatment-resistant depression diagnosed by a psychiatrist.
4. Confirmation you’re 18 or older and treatment is prescribed by a psychiatrist.
5. Prescription monitoring database check showing your controlled substance prescription history from your state.
6. Documentation about psychosis history (either none, or explanation of why benefits outweigh risks if you have history).
7. Your clinic can reference the Cigna Spravato prior authorization form, though they handle all submission.

• Spravato is typically covered under Cigna’s pharmacy benefit as a specialty medication, not medical benefit.
• Specialty tier coinsurance: Most Cigna plans charge 25-33% coinsurance for specialty medications after deductible.
• Your deductible applies first – you pay full cost until you meet your annual deductible.
• After deductible, you pay your coinsurance percentage until you reach your out-of-pocket maximum.
• Treatment schedule: Twice weekly for 4 weeks, then weekly for 4 weeks, then every other week or weekly for maintenance.
• Facility and monitoring costs may apply separately for the 2-hour observation period after each dose.
• Use my Spravato insurance cost calculator to get a personalized estimate based on your specific plan details.

• Member Services: 1-800-997-1654 (available 24 hours a day, 365 days a year)
• TTY for hearing impaired: 711
• Access your Cigna member portal to check your benefits and coverage details.
• Visit Cigna contact and support options for additional help and resources.

• Policy name: Psychiatry – Spravato Prior Authorization Policy.
• Review date: January 29, 2025 (selected revision May 28, 2025).
• Approval duration: 6 months for treatment-resistant depression.
• Applies to: Cigna commercial health plans administered by Cigna companies.
• View the complete policy at Cigna’s official Spravato coverage policy.
• Prior authorization form: Cigna Spravato PA form (your clinic submits this, not you).

This section translates Ambetter’s clinical policy into plain language; your clinic uses it to decide whether you meet the rules.

You never submit this yourself; the psychiatrist and staff match your records to these criteria during the Spravato evaluation visit.

• Age 18 to 64 with a diagnosis of treatment-resistant depression from a qualified mental health professional.
• Baseline PHQ-9 depression score around 15 or higher within the last month, showing moderately severe symptoms despite treatment.
• Failure of at least two antidepressants from different types taken at right doses for four or more weeks each.
• Failure of one add-on medication such as an atypical antipsychotic, lithium, thyroid hormone, buspirone, or similar agent.
• For suicidal depression, recent hospital stay or crisis-level care plus high scores on standard depression rating scales may be required.
• Spravato must be given in a REMS-certified clinic that can monitor blood pressure, breathing, and dissociation on-site.
• Ambetter excludes people with certain aneurysms, brain bleeding history, or strong allergy to ketamine or esketamine ingredients.

Your clinic also checks for substance use, bipolar disorder, or psychosis that might need separate treatment before starting Spravato.

After your evaluation, the clinic’s insurance staff sends Ambetter a detailed request so they can decide whether to cover Spravato.

You sign releases and answer questions, but you do not fill out Ambetter forms yourself or argue with the health plan.

1. Medication history listing each antidepressant, maximum doses, dates, and whether you stopped for side effects or lack of benefit.
2. Summary of add-on medication trials like atypical antipsychotics, lithium, thyroid hormone, or buspirone, with notes showing proof it didn’t work.
3. Recent PHQ-9, MADRS, or HAMD scores documenting how severe your depression is now and how it changed with treatment.
4. Descriptions of suicidal thoughts, hospital stays, or crisis visits if Ambetter is reviewing you under the suicidal depression pathway.
5. Safety screening showing blood pressure, substance use history, pregnancy status, and other conditions that might change how Spravato is given.
6. Clinic attestation that treatment occurs in a REMS-certified center with monitoring, transport home plans, and no take-home Spravato devices.
7. Completed Ambetter Medication Prior Authorization Request Form or electronic PA submission through CoverMyMeds with supporting chart notes and rating scales.

Ambetter often responds quickly once everything is submitted; your clinic follows up if the health plan asks for clarifications.

Ambetter covers most of the Spravato cost once you are approved, but your share depends on your specific marketplace plan design.

Your Spravato clinic can pull a real-time benefits quote from Ambetter before you begin, so you know the likely range.

• Spravato is treated as a specialty drug and billed under medical, pharmacy, or both, depending on your Ambetter plan.
• Many plans require you to meet your yearly deductible before Ambetter starts paying a percentage of Spravato visit costs.
• After the deductible, you pay coinsurance, a percentage of each allowed Spravato claim, until you reach your out-of-pocket maximum.
• Each visit bundles the drug, clinic time, monitoring, and observation into codes that count toward your medical out-of-pocket maximum.
• Early weeks involve more frequent visits, then Ambetter allows maintenance visits every one or two weeks if you are improving.
• Use my Spravato insurance cost calculator to estimate your share based on your deductible, coinsurance, and out-of-pocket maximum.
• You and your clinic can confirm Spravato’s tier and limits in your state’s Ambetter formulary or online drug list tool.

Bring your Ambetter ID card to the first visit so staff can run the most accurate quote.

Because Ambetter is offered by different Centene companies in many states, the exact phone number on your card may vary.

Use the contacts below as starting points, but always trust the Member Services number printed on your Ambetter ID card first.

• Member Services: call the customer service phone number on your Ambetter card to ask about Spravato coverage and costs.
• If you misplaced the card, start at the Ambetter Contact Us page and choose your state.
• Many states list a general Member Services line such as 1-877-687-1180 with TTY access through 711 relay services.
• Use your Ambetter online member account to review benefits, deductibles, and recent claims any time.
• For extra help, visit the Ambetter Help Center for FAQs and links into your state’s site.
• If your plan is labeled Ambetter Health Solutions, your Member Services contact will still appear on that same insurance card.

Bring your card to the clinic visit so staff can call Ambetter with you if any coverage questions come up.

Ambetter health plans use a shared Centene clinical policy for Spravato called CP.PMN.199; your clinic leans heavily on this document.

Knowing the basics can make it easier to follow what staff mean when they reference “the policy” during your visits.

• Policy name: Clinical Policy Esketamine (Spravato) with detailed criteria for treatment-resistant depression and major depression with suicidal symptoms.
• Reference number: CP.PMN.199, used by Ambetter, Health Net, and other Centene plans across commercial, marketplace, and Medicaid lines.
• Effective date: 06/01/2019 with later revisions; last review noted as 2025 in the revision log of the current document.
• Applies to: many Ambetter marketplace plans and related Centene products; exact coverage still depends on your individual contract language.
• The policy spells out age ranges, PHQ-9 thresholds, failed medication rules, add-on medication expectations, and detailed dosing and device limits.
• View the complete policy at Ambetter’s official Spravato coverage policy used by your clinic when requesting approval.
• Clinics pair this policy with an Ambetter Medication Prior Authorization Request Form or electronic PA to document medical necessity.

Updates to CP.PMN.199 appear in Ambetter provider news, but your clinic tracks those changes so you do not have to.

These criteria come from Highmark’s Spravato medical policy I-212 for commercial plans; your clinic will match your chart to them during the evaluation. They also outline a pathway for severe episodes with suicidal thoughts or recent suicide-related care.

• Age 18 or older with major depressive disorder diagnosed by a psychiatrist or other qualified mental health prescriber.
• For treatment-resistant depression, at least three antidepressants from different types tried at right dose and duration with proof they failed.
• At least one failed antidepressant trial happened during your current depressive episode, not only during earlier episodes years ago.
• At least one add-on medication trial, such as an atypical antipsychotic, lithium, thyroid hormone, or a similar agent.
• For the suicidal depression pathway, documentation of active suicidal ideation with intent and, often, crisis or inpatient care this episode.
• Treatment takes place only in a Spravato REMS-certified clinic that can monitor blood pressure, thinking changes, and breathing on-site.
• Exclusions include recent moderate or severe substance use disorder, psychotic disorders, and certain unstable medical problems that make Spravato unsafe.

Highmark also expects you to keep taking an oral antidepressant with Spravato and to show improvement on depression rating scales over time.

Your clinic’s insurance team handles the entire Highmark prior authorization process after your evaluation; you do not fill out any of these forms yourself. They pull information from your chart, intake paperwork, and rating scales.

1. Diagnosis documentation showing treatment-resistant major depressive disorder or major depressive disorder with acute suicidal ideation, including severity level.
2. Medication history listing at least three antidepressants, with names, doses, dates, and notes that each did not relieve symptoms enough.
3. Evidence of at least one add-on medication trial, such as two antidepressants together or an antidepressant plus another agent.
4. Depression rating scale scores, often Montgomery-Åsberg or PHQ-9, showing how severe symptoms were before starting Spravato.
5. Safety screening for substance use disorder, psychosis, uncontrolled blood pressure, and other conditions that could make Spravato risky.
6. Confirmation that Spravato will be given in a REMS-certified clinic, with observation for at least two hours after each dose.
7. Requested dosing schedule, planned start date, and whether costs will be billed under your medical or pharmacy benefit.

Highmark reviews this packet and either approves the request, asks for more information, or denies it; your clinic explains the decision and next steps.

Spravato can be covered under either the medical or pharmacy side of your Highmark benefit, depending on your plan and clinic billing.

Your actual out-of-pocket cost depends on your deductible, coinsurance, visit copays, and how quickly you reach your plan’s yearly out-of-pocket maximum.

• If billed under the medical benefit, you may pay a specialist visit copay plus a percentage of the procedure charge.
• If billed under the pharmacy benefit, Spravato is treated as a specialty drug, often with higher coinsurance than regular generics.
• Early in the year, the allowed charge first applies to your deductible; after meeting it, you pay coinsurance or copays.
• Once you hit your plan’s out-of-pocket maximum, Highmark pays allowed Spravato costs for the rest of the policy year.
• Treatment starts twice weekly, then decreases to weekly and eventually every one to two weeks, which changes your monthly total.
• Use my Spravato insurance cost calculator to estimate costs based on your Highmark deductible, out-of-pocket maximum, and coinsurance.

You can also log in to your Highmark member portal and use their drug list and cost estimator tools to confirm how Spravato is covered on your specific plan.

Most questions about Spravato coverage are answered fastest by calling the Member Services number on your Highmark ID card.

Use the numbers and links below if you do not have your card handy or need help signing in online.

• Member Services: call the phone number on the back of your Highmark Blue Cross Blue Shield ID card first.
• General information line for Highmark plans: 866-459-4418 for benefit questions if you cannot find your ID card.
• TTY users can dial 711 to reach relay services, then ask the operator to connect you with Highmark.
• Log in to the My Highmark member portal to review benefits, claims, and prior authorization decisions.
• Visit Highmark’s contact and support page for additional phone numbers by state and plan type.

When you call, say you are asking about Spravato nasal spray for depression and whether your plan covers it.

Then confirm which clinics near you are in-network and how many treatment visits count as mental health office visits.

These documents show how Highmark thinks about Spravato coverage on the medical side; your actual benefits still depend on your specific plan contract.

Clinics and insurance teams use them to double-check that your history fits the criteria before sending in a prior authorization request.

• Policy name: I-212 Esketamine Spravato commercial medical policy for Highmark Blue Cross Blue Shield plans.
• Document ID and version: I-212-007 for Pennsylvania commercial plans, with similar I-212 versions used in other regions.
• Effective date and last review: effective August 5, 2024, with annual review and revision noted in the policy header.
• Applies to: most Highmark commercial lines of business; Medicare, Medicaid, or exchange plans may use related criteria documents.
• View the complete policy at Highmark’s Spravato coverage policy I-212 for the full treatment-resistant and suicidal depression criteria.
• For Medicaid members, clinics may use the Highmark Health Options prior authorization form to document rating scales and medication trials.

You do not need to read these documents yourself; knowing they exist can reassure you that your clinic is following written, reviewable rules instead of making decisions on the spot.

These points summarize Blue Cross NC’s corporate Spravato medical policy; your clinic compares your chart to these rules during the evaluation. You do not have to manage this yourself.

• Age 18 or older with a confirmed diagnosis of major depressive disorder, single episode or recurrent, without psychotic features.
• Treatment-resistant depression path: current episode has not improved enough after at least two antidepressants from different types.
• Each antidepressant was taken at a right dose for around six weeks, with proof in your chart that symptoms stayed severe.
• Suicidal depression path: major depressive disorder with imminent suicidal ideation or behavior serious enough to consider hospitalization.
• Baseline depression score of at least 28 on the MADRS scale, or a similar standardized depression rating scale, before starting Spravato.
• No Spravato if you are also receiving ketamine by any route for the same condition, to avoid unsafe duplication of effect.
• No known aneurysmal vascular disease, intracerebral hemorrhage, or other major contraindications that make Spravato too risky.
• Spravato is prescribed by a psychiatrist and given only at a REMS-certified clinic with on-site monitoring and proper billing codes.

For continued approval, Blue Cross NC expects at least a 50 percent drop in your depression score over time while you stay on an oral antidepressant.

Your clinic’s insurance team handles the entire Blue Cross NC approval packet after your evaluation; you do not fill out these forms. They pull details from your records and standardized scales.

1. Diagnosis summary confirming treatment-resistant major depressive disorder or major depressive disorder with acute suicidal ideation or behavior.
2. Medication timeline listing at least two antidepressants from different types, with names, doses, dates, and limited improvement notes.
3. Documentation that each medication was taken at the right dose and long enough to judge whether it helped your symptoms.
4. Depression rating scale scores, usually MADRS or a similar tool, showing severity before starting Spravato and at follow-ups.
5. Screening for substance use, psychosis, blood pressure problems, aneurysmal disease, and other medical safety issues.
6. Confirmation that a psychiatrist will prescribe Spravato and that dosing will occur in a REMS-certified clinic with two-hour observation.
7. Requested dosing plan, expected start date, and whether charges will run through the medical benefit, pharmacy benefit, or a mix of both.
8. When needed, clinics can also use Blue Cross NC’s esketamine prior review request form and fax it to the medical review department.

Blue Cross NC reviews this information, decides on approval or denial, and may request more details; your clinic explains the result and options.

Spravato is a restricted drug that may process under your Blue Cross NC medical benefit, pharmacy benefit, or both, depending on how the clinic bills.

Your personal cost depends on your deductible, coinsurance, visit copays, and when you hit your plan’s out-of-pocket maximum for the year.

• Under the medical benefit, you may see specialist visit copays plus a percentage of the procedure and monitoring charge.
• Under the pharmacy benefit, Spravato is treated as a specialty drug with higher coinsurance than many regular generic medications.
• At the start of the year, allowed charges may first apply to your deductible before coinsurance or copays begin.
• After you reach your out-of-pocket maximum, Blue Cross NC pays allowed Spravato costs for the rest of the plan year.
• Induction involves twice-weekly visits, then weekly, then every one to two weeks, so monthly visit counts change over time.
• Use my Spravato insurance cost calculator to estimate costs based on your Blue Cross NC deductible, out-of-pocket maximum, and coinsurance.

Your clinic can also run estimates using Blue Cross NC tools and your specific plan so you know expected costs before starting.

The fastest way to confirm Spravato coverage is to call the Member Services number on your Blue Cross NC ID card.

If you cannot find your card, you can use the general customer service line and online tools listed here.

• Member Services: first, call the phone number printed on the back of your Blue Cross NC member ID card.
• If you do not have your card, call Blue Cross NC Customer Service at 877-258-3334 for benefit questions.
• TTY users can dial 711 to use relay services and ask to be connected to Blue Cross NC Customer Service.
• Log in to the Blue Connect member portal to review benefits, claims, and approval decisions.
• Visit the Blue Cross NC contact and support page for additional numbers by plan type and location.

When you call, say you are asking whether Spravato nasal spray for depression is covered on your plan and which clinics are in-network.

This snapshot shows the key Blue Cross NC documents clinics rely on when they request Spravato for you. Your own plan contract still controls final benefits.

• Policy name: Corporate Medical Policy – Esketamine (Spravato) Nasal Spray “Notification,” medical benefit.
• Effective date: policy effective January 1, 2026, with earlier updates in 2021, 2023, 2024, and 2025 noted in the history.
• Criteria highlights: age 18 or older, qualifying major depressive disorder diagnosis, two failed antidepressants from different types, rating scale thresholds.
• Safety rules: no concurrent ketamine for the same condition, and no use with aneurysmal vascular disease or intracerebral hemorrhage.
• Applies to: most commercial Blue Cross NC plans; Medicare, Medicaid, and other products may use related benefit documents.
• View the complete policy at Blue Cross NC’s Spravato coverage policy for full criteria and dosing tables.
• Your clinic may also use the esketamine prior review request form when faxing medical information for approval.

You never need to submit these forms yourself; knowing they exist simply confirms there are written rules your clinic is following on your behalf.

This section summarizes Blue Cross Blue Shield of Massachusetts necessity rules for Spravato; your clinic uses them to judge eligibility.

You never submit this list yourself; the psychiatrist and staff match your records to these items during evaluation.

• Age 18 or older with major depressive disorder diagnosed using standard criteria, without schizophrenia or schizoaffective disorder.
• For treatment-resistant depression, current episode remains severe despite at least two adequate antidepressant trials from different medication types.
• Some members may qualify under a severe suicidal depression pathway, with recent suicidal thoughts, plans, or hospital-level crisis care.
• Baseline depression rating scale scores, such as MADRS or PHQ-9, must show at least moderate-to-severe symptom levels.
• Spravato must be given in a REMS-certified clinic with blood pressure monitoring, observation, and safe transport arrangements after visits.
• Members cannot receive Spravato if they have certain aneurysmal vascular diseases, recent brain bleeding, or other serious contraindications.
• For continued approval, the policy expects meaningful symptom improvement and ongoing use of an oral antidepressant alongside clinic Spravato sessions.

Your clinic also screens for substance use disorders, unstable medical conditions, and pregnancy, which can change timing or safety of Spravato.

After your evaluation, the clinic insurance team prepares a request packet for Blue Cross Blue Shield of Massachusetts using Authorization Manager or fax forms.

You sign releases and answer questions, but staff complete the medical paperwork and talk to the plan if reviewers need more detail.

1. Diagnosis summary confirming treatment-resistant major depressive disorder and, when relevant, documentation of current severe suicidal thoughts or behaviors.
2. Antidepressant history listing names, doses, dates, and why each medication was stopped, showing proof it did not work.
3. Information on any add-on medications, such as atypical antipsychotics or lithium, including doses, timelines, and limited symptom response.
4. Recent depression rating scale scores, like MADRS or PHQ-9, showing how severe symptoms are before starting clinic Spravato sessions.
5. Safety screening details, including blood pressure readings, substance use history, pregnancy status, and other conditions that affect Spravato risks.
6. Confirmation that Spravato will be given only in a REMS-certified clinic, with observation and safe-transport plans after every treatment.
7. Completed Blue Cross Blue Shield of Massachusetts request form #094 or electronic submission through Authorization Manager with attached chart notes.

If Blue Cross Blue Shield of Massachusetts asks for more information, your clinic responds directly; you do not negotiate with reviewers yourself.

Spravato is a high-cost, restricted drug; Blue Cross Blue Shield of Massachusetts may process claims under your medical benefit, pharmacy benefit, or both.

Your share depends on your deductible, coinsurance, visit copays, and how quickly you hit the yearly out-of-pocket maximum.

• If billed as a medical service, you may owe a specialist copay plus part of the allowed clinic charges.
• If billed under the pharmacy benefit, Spravato is treated as a specialty medication with higher coinsurance than many generic drugs.
• Early induction weeks involve two visits per week, then weekly, then every one or two weeks once your symptoms improve.
• Each visit bundles the drug, administration, monitoring, and observation time into claim codes that count toward your yearly limits.
• Once you reach the out-of-pocket maximum, Blue Cross Blue Shield of Massachusetts pays charges for the rest of the year.
• Use my Spravato insurance cost calculator to estimate your share based on deductible, coinsurance, and out-of-pocket maximum.
• Your clinic can also check Blue Cross Blue Shield of Massachusetts tools to see Spravato’s tier and typical allowed amounts.

Bring your Blue Cross Blue Shield of Massachusetts ID card to the first visit so staff can run the most accurate quote.

Most coverage questions are answered fastest by calling the Member Service number printed on your Blue Cross Blue Shield of Massachusetts ID card.

If you do not have the card nearby, use these contacts to reach the plan or sign in online.

• Member Service: 1-800-262-2583 is the main customer service number for many Blue Cross Blue Shield of Massachusetts plans.
• TTY users can dial 711 and ask the relay operator to connect with Blue Cross Blue Shield of Massachusetts.
• Use the MyBlue member portal to review benefits, claims, deductibles, and previous approval decisions.
• The main Blue Cross Blue Shield of Massachusetts website at bluecrossma.org links to plan tools and program information.
• For Medicare Advantage members, contact numbers on your Medicare-specific card or the Medicare contact page may be different.
• Always have your ID card handy when calling so staff can see your product line, copays, and mental health benefits.

You can also bring your card to the clinic and ask staff to call Blue Cross Blue Shield of Massachusetts with you.

These documents show how Blue Cross Blue Shield of Massachusetts structures Spravato coverage; your individual contract still controls final payment details.

Clinics rely on them to confirm that you meet written criteria instead of guessing based on personal opinions or sales materials.

• Policy name: Esketamine Nasal Spray (Spravato) and Intravenous Ketamine for Mental Health Conditions, medical policy number 087.
• Effective date: policy version effective January 1, 2023, with earlier and later updates listed in the policy’s revision history.
• Applies to: many commercial Blue Cross Blue Shield of Massachusetts products; Medicare and Medicaid lines may rely on related documents.
• The policy explains indications, dosing schedules, rating scale thresholds, continuation rules, and when intravenous ketamine may be considered medically necessary.
• View the full policy at Blue Cross Blue Shield of Massachusetts’s official Spravato coverage policy.
• For paper or fax submissions, clinics use the Esketamine request form 094 aligned with the same criteria.
• Providers are directed to submit requests through Authorization Manager when possible, which speeds review and lets them track status electronically.

You never have to download these documents yourself; your Spravato clinic keeps the latest versions and follows them on your behalf.

This section explains Blue Cross Blue Shield of Michigan’s full clinical rules for Spravato. Your Spravato clinic checks these details against your chart during the evaluation and tells you whether you truly match the policy.

• Adults 18 or older with treatment-resistant depression or major depression with suicidal thoughts, confirmed by a psychiatrist.
• For TRD, at least two antidepressants and two add-on medications were used together without enough benefit despite right doses.
• Each antidepressant and add-on combination lasted about six weeks with chart notes showing proof it did not work.
• You also received weekly cognitive behavioral therapy or interpersonal therapy for at least eight weeks in this episode.
• For TRD, Blue Cross now allows Spravato alone or with an antidepressant after a 2025 label update.
• Spravato must be given in a certified clinic under monitoring, not with IV ketamine or unsupervised home use.
• Additional Blue Cross safety checks can include substance use screening and reviewing other conditions that might make Spravato unsafe.

Your clinic’s insurance team handles the entire Blue Cross Blue Shield of Michigan approval process after your evaluation. This section shows what they send to Blue Cross so you understand what is happening behind the scenes.

1. List of your failed antidepressant and add-on medication combinations, including names, doses, dates, and why they did not work.
2. Depression rating scale scores, such as PHQ-9 or similar tools, showing your symptoms stayed severe enough despite those treatments.
3. Documentation of your current diagnosis, level of impairment, suicidal thoughts if present, and why Spravato is now being recommended.
4. Notes confirming you received psychotherapy, medication adjustments, and other standard treatments before Spravato, in line with Blue Cross policy.
5. Safety screening results, such as substance use history, blood pressure concerns, and other conditions that could raise Spravato risks.
6. Submission of the Spravato Medication Authorization Request Form plus required chart notes through the Blue Cross authorization portal or fax.

Spravato is billed under your medical benefit with Blue Cross Blue Shield of Michigan, not as a typical pharmacy prescription. Your exact out-of-pocket costs depend on your specific plan design, deductible, and coinsurance levels.

• Most Spravato charges appear as medical benefit claims, including the drug, nursing time, monitoring, and use of the treatment room.
• Some employer or union plans may process Spravato differently, so the same Blue Cross card can have different cost structures.
• Your deductible must often be met before Blue Cross pays most of the bill, especially early in the calendar year.
• Coinsurance means you pay a percentage of each visit, which can be large until you hit your annual out-of-pocket maximum.
• Facility fees for the clinic, nursing supervision, and monitoring afterward are part of the medical claim, not billed separately.
• Use my Spravato insurance cost calculator to estimate your share based on deductible, coinsurance, and out-of-pocket maximum.
• If you have a self-funded employer plan, your Spravato costs may follow additional rules set by that employer.

Most questions about Spravato benefits are answered fastest by calling the customer service number on the back of your Blue Cross Blue Shield of Michigan member ID card. This section gives you quick links if you prefer online tools.

• Call the number printed on your Blue Cross or Blue Care Network ID card for plan-specific Spravato coverage questions.
• TTY users can dial 711 to reach Blue Cross customer service through the Telecommunications Relay Service.
• Use the Blue Cross Blue Shield of Michigan member portal to review benefits, claims, and authorization status.
• For more ways to reach Blue Cross, use the online contact and support options page and choose your plan type.
• Medicare, Medicaid, and employer-sponsored plans may post additional contact numbers on separate mailings for those products.

This accordion gives you a snapshot of the official Spravato policy documents Blue Cross Blue Shield of Michigan uses. Most patients never need to read these, but they are helpful if you like to double-check the source material.

• Policy name: Spravato (esketamine) medical benefit drug policy for Blue Cross Blue Shield of Michigan and Blue Care Network.
• Document ID: 2107714, posted as a PDF on the Blue Cross Blue Shield of Michigan medical policy website.
• Current policy effective date: August 1, 2025, with earlier versions dating back to 2019 listed in the policy history.
• Applies primarily to Michigan commercial Blue Cross and Blue Care Network plans; Medicare and self-funded groups may use different criteria.
• View the complete policy at Blue Cross Blue Shield of Michigan’s official Spravato coverage policy.
• Prescribers also use the Spravato Medication Authorization Request Form when submitting detailed prior authorization requests for commercial members.

These criteria are taken from Horizon Blue Cross Blue Shield of New Jersey’s Spravato medical policy 191; your clinic matches your chart to them.

You never submit this list yourself; the psychiatrist and staff decide whether your history actually fits Horizon’s written rules.

• You are at least 18 years old with major depressive disorder confirmed by a qualified mental health clinician.
• Your depression is single-episode lasting two years or longer, or recurrent without any psychotic features.
• You had poor response to at least two antidepressants taken six weeks or more with strong adherence to dosing.
• Your baseline depression rating score is at least twenty-eight on the MADRS or a similar validated scale.
• You will take Spravato together with an oral antidepressant, never as stand-alone treatment for your depression.
• You have no major contraindications such as aneurysmal vascular disease, intracerebral hemorrhage, or uncontrolled serious medical conditions.
• Spravato is given only in a REMS-certified clinic by trained staff with on-site monitoring and emergency support available.

For ongoing approval, Horizon expects clear depression improvement, no serious side effects, and no signs of misuse or abuse during treatment.

After your evaluation, the clinic’s insurance team handles Horizon’s approval request; you do not complete these forms or argue criteria yourself.

This list simply shows what they send so you understand the work happening behind the scenes.

1. Diagnosis summary confirming treatment-resistant major depressive disorder or major depressive disorder with active suicidal thoughts or behaviors.
2. Timeline of at least two antidepressant trials, including names, doses, dates, and limited benefit despite right dosing and duration.
3. Details of any add-on medications or intensive therapies used before Spravato, with notes about ongoing severe symptoms.
4. Baseline and follow-up depression rating scale scores, such as MADRS, showing severity and later improvement where present.
5. Medical safety screening results covering substance use, pregnancy status, blood pressure, and other conditions that affect Spravato risks.
6. Confirmation that Spravato will be given only in a REMS-certified clinic with monitoring and reliable transportation home after visits.
7. Planned dosing schedule for induction and maintenance, along with expected start date and relevant Horizon billing codes.
8. Use of Horizon pharmacy or medical request forms, or electronic portals, to submit clinical details and track decision status.

If Horizon asks for more information, your clinic responds directly and later explains the decision and any appeal options.

Spravato is a high-cost, restricted drug; Horizon may process charges under your medical benefit, pharmacy benefit, or a mix of both.

Your personal costs depend on your benefit design, deductible, coinsurance levels, visit copays, and when you reach your out-of-pocket maximum.

• Under the medical benefit, you may pay specialist visit copays plus a percentage of allowed clinic charges.
• When processed under the pharmacy benefit, Spravato is treated as a specialty drug with higher member coinsurance.
• Early in the year, Spravato visit costs may first apply toward your annual deductible before coinsurance begins.
• Coinsurance means you pay a set percentage of each approved claim until you reach your out-of-pocket maximum.
• Induction involves twice-weekly sessions, then weekly, then every one or two weeks as your response stabilizes.
• Clinic bills usually bundle drug, nursing time, monitoring, and recovery space into one or more medical claims.
• Use my Spravato insurance cost calculator to estimate your share based on your Horizon deductible and coinsurance.
• Your Spravato clinic can also run a benefits check with Horizon so you see estimates before starting treatment.

Most benefit questions are answered fastest by calling the number on your Horizon ID card; staff can see your exact product and copays.

If you do not have the card nearby, these general contacts help you reach Horizon or sign in to online tools.

• For commercial and many employer plans, Member Services is available at 1-800-355-BLUE, which is 1-800-355-2583.
• TTY users can dial 711 to reach Horizon Blue Cross Blue Shield of New Jersey through the relay service.
• Use the Horizon member portal at horizonblue.com/members to review benefits, claims, authorizations, and deductible progress.
• You can also use the secure message tools inside the member portal to ask nonurgent Spravato coverage questions.
• The main member contact page at horizonblue.com/contact-us/member-contacts lists additional numbers by plan type.
• Medicare, Medicaid, and other specialized products may post different phone numbers, printed on your specific ID card.
• Always have your Horizon ID card handy so staff can quickly locate your account and benefits.

This snapshot highlights the Horizon policies your clinic references when asking for Spravato approval; always confirm current details on Horizon’s website.

Commercial, Medicare Advantage, and Horizon NJ Health Medicaid products may reference different documents, but they use similar core criteria. Future revisions may change wording, but the basic structure of criteria has stayed stable across recent years.

• Policy name: Esketamine, Spravato, Uniform Medical Policy Manual, Section Drugs, Policy Number 191, Horizon BCBSNJ.
• Effective date: 09/11/2020 with original policy date 04/23/2019 and last review noted as 09/08/2020.
• This policy applies to many Horizon commercial and Medicare Advantage products when Spravato is billed under medical benefits.
• Medicaid members use the Horizon NJ Health drug policy, linked from Horizon’s site under the Esketamine, Spravato entry.
• You and your clinic can view Horizon BCBSNJ’s Spravato coverage policy at Horizon BCBSNJ’s official Spravato coverage policy.
• Horizon NJ Health members can review related Medicaid policy information through services3.horizon-bcbsnj.com/ddn/NJhealthWeb.nsf.
• Your clinic keeps copies of these policies and uses them to document why your case meets Horizon’s medical-necessity standards.

These details come from Independence Blue Cross medical policy 08.01.80c for intravenous ketamine and intranasal Spravato.

Your clinic compares your chart against this list; you never submit the policy or argue exact wording yourself.

• Age eighteen or older with major depressive disorder diagnosed using DSM-5TR criteria by a qualified clinician.
• Depression episode lasting at least two years or recurrent major depression without any psychotic features.
• Severe symptoms shown on a validated depression rating scale such as MADRS, PHQ-9, BDI-II, or HAM-D.
• Less than twenty-five percent improvement after two antidepressants from different types, taken six weeks at right doses.
• No moderate or severe alcohol or substance use disorder within six months before screening for Spravato treatment.
• No current or past psychotic disorder and no positive tests for cocaine, PCP, or unprescribed stimulants.
• Not receiving transcranial magnetic stimulation at the same time as Spravato treatment sessions for depression.
• Spravato prescribed by or in consultation with a psychiatrist or other licensed behavioral health professional.
• All doses given in a supervised clinic with at least two hours of post-dose monitoring and vital checks.

For ongoing authorization, Independence expects rating-scale improvement, continued combined oral medication, and no serious safety problems or misuse.

After your evaluation, the clinic’s insurance staff handles Independence Blue Cross’s approval request; you do not complete these forms.

This list shows the information they send so Independence can confirm medical necessity under policy 08.01.80c.

1. Diagnosis of treatment-resistant major depressive disorder or major depression with acute suicidal thoughts, confirmed by a mental health professional.
2. Depression rating-scale scores before starting Spravato and after treatment, such as MADRS, PHQ-9, HAM-D, or BDI-II.
3. History of at least two antidepressant trials, including names, doses, dates, duration, and limited benefit at right doses.
4. Details on any add-on medications or therapies used, showing significant symptoms despite carefully followed treatment plans.
5. Safety screening results covering medical history, blood pressure, pregnancy status, and substance use, including required urine drug testing.
6. Confirmation that Spravato will be administered only in a REMS-certified clinic with onsite monitoring and emergency support available.
7. Completed Independence Blue Cross request forms or electronic submissions, plus prescribing provider information and planned dosing schedule.

If Independence needs clarification, your clinic responds directly and then tells you whether treatment was approved, denied, or appealed.

Spravato is a high-cost specialty drug; Independence may process charges under your medical benefit, pharmacy benefit, or both.

Your share depends on deductible status, coinsurance level, visit copays, and how quickly you reach your out-of-pocket maximum.

• Under medical benefits, you may owe specialist copays plus a percentage of clinic and monitoring charges each visit.
• When billed under pharmacy benefits, Spravato is usually placed on a specialty tier with higher member coinsurance.
• Before meeting your deductible, you may pay the full allowed amount for Spravato-related claims until it is satisfied.
• After the deductible, coinsurance applies until total spending reaches your Independence out-of-pocket maximum for the year.
• Induction requires twice-weekly visits four weeks, then weekly and less often during maintenance if response is sustained.
• Clinic bills usually include drug, nursing time, observation room, monitoring, and any required labs or pregnancy tests.
• Use my Spravato insurance cost calculator to estimate your share based on your Independence plan details.

Your Spravato clinic can run a benefits investigation with Independence and share clearer estimates before you begin treatment.

For Spravato coverage questions, the fastest route is calling the number on your Independence Blue Cross ID card. Phone staff see your plan details instantly.

If you do not have the card nearby, these general contacts can help you reach the right team.

• Commercial member services: 1-800-ASK-BLUE (1-800-275-2583), Monday through Friday, 8 a.m. to 6 p.m.
• TTY users can dial 711 to reach Independence Blue Cross through the telecommunications relay service.
• Use the secure member portal at ibx.com/login to review benefits, claims, and authorizations.
• Visit the general contact page at ibx.com/contact-us for additional phone numbers by product line.
• If you have Medicare or Medicaid through Independence, use the program-specific numbers printed on your ID card.
• You can also send nonurgent questions through secure messages once you are logged in to the portal.

Always have your ID card ready when you call so staff can quickly see your exact Independence benefits.

These points summarize Independence Blue Cross medical policy 08.01.80c for intravenous ketamine and intranasal Spravato.

Your clinic pulls the current version from the Independence policy portal when requesting coverage and follows that wording.

• Policy name: Intravenous Ketamine (Ketalar) and Intranasal Esketamine (Spravato).
• Policy number: 08.01.80c in the commercial medical policy bulletin library for Independence Blue Cross.
• Version effective date: July 1, 2024; earlier notices show original policy effective April 4, 2022.
• Benefit application states ketamine and Spravato are covered under medical benefits when listed criteria are satisfied.
• Coverage applies to many commercial Independence products; individual contracts and pharmacy benefits can change claim handling.
• View Independence Blue Cross’s official Spravato coverage policy at Independence Blue Cross’s official Spravato coverage policy.
• Providers also use Independence pharmacy prior authorization forms when Spravato is handled through the drug benefit.

Policies can be updated; your clinic checks the portal for new versions, especially if criteria or dosing language change.

These details are for your understanding only and not a checklist you need to complete. During your evaluation, the Spravato clinic team confirms whether you meet each requirement BlueCross BlueShield of Tennessee uses for coverage.

• You have severe major depressive disorder, single or recurrent episode, measured by standardized depression rating scales.
• You are at least 18 and symptoms significantly impair work, relationships, or basic self-care.
• For treatment-resistant depression, you tried two antidepressants from different types at the right dose for eight weeks each.
• You also had at least eight weeks of an add-on medication or structured psychotherapy, without enough improvement.
• For suicidal depression, you have current suicidal thoughts with intent and serious risk of needing inpatient care.
• You have no uncontrolled moderate or severe alcohol or substance use disorder that is not actively managed.
• Treatment happens in a REMS-certified Spravato clinic with staff able to monitor your blood pressure and recovery safely.

Your clinic’s insurance team handles this entire process after your evaluation; you never complete these forms or call BlueCross yourself about Spravato coverage.

1. List of failed antidepressants with drug names, doses, dates, and notes showing poor response or intolerable side effects.
2. Documentation of any add-on medications or structured psychotherapy tried, with timing and results for this depressive episode.
3. Baseline depression rating-scale scores, such as PHQ-9, HDRS, MADRS, or similar tools required by the policy.
4. Clinical notes confirming diagnosis, severity, functional impairment, and whether treatment is for treatment-resistant depression or suicidal depression.
5. Safety screening results covering substance use, psychosis, blood pressure, medical conditions, and any reasons Spravato could be unsafe.
6. Attestation that Spravato will be given in a REMS-certified clinic, with at least two hours of on-site monitoring.
7. The BlueCross BlueShield of Tennessee or CVS Caremark authorization form used for Spravato coverage review and renewal decisions.

Your exact costs depend on your specific BlueCross BlueShield of Tennessee benefit design, including deductibles and copays. These points give you a framework for questions during your clinic’s benefits review.

• Many plans cover Spravato under the pharmacy benefit as a specialty drug; some handle it under the medical benefit instead.
• You may pay a percentage coinsurance for each treatment until you meet your annual deductible and out-of-pocket maximum for Spravato.
• Clinic visit charges, monitoring time, and facility fees may be billed separately from the Spravato drug itself on your account.
• During the first month, treatment visits are more frequent; later maintenance visits spread out but still count toward cost limits.
• Use my Spravato insurance cost calculator to estimate your costs using your deductible, coinsurance, and out-of-pocket maximum.
• Ask the clinic whether your plan requires any extra reviews that could affect timing or your total Spravato costs.

Use this information if you want to contact BlueCross directly about Spravato coverage; your clinic can also call on your behalf instead of you managing every detail alone.

Always check the phone number printed on the back of your member ID card, because some plans use dedicated service numbers.

• General Member Services for many commercial plans: 1-800-565-9140 for benefit and coverage questions.
• TTY for hearing support: 1-800-848-0298 or 711, matching the instructions printed on many ID cards.
• BlueCross BlueShield of Tennessee member portal to view benefits, claims, pharmacy coverage, and cost estimates.
• BlueCross BlueShield of Tennessee contact page for plan-specific numbers, mailing addresses, and current service hours.
• For Medicare, Medicaid, or Marketplace products, use the contact page sections that match your specific program.
• If clinic staff call while you listen, have your ID card ready and ask them to confirm benefits and costs.

These details describe the coverage document your Spravato clinic references when requesting BlueCross BlueShield of Tennessee approval and when renewing treatment after the first authorization period. You do not need to read it, but knowing it exists can be reassuring.

• Policy name: Spravato (esketamine) – Specialty Guideline Management criteria used by BlueCross BlueShield of Tennessee and CVS Caremark.
• Document ID: 2889-A, listed on each page of the CVS Caremark Spravato guideline document and related materials.
• Last reviewed: 2024 P2024a version, which cites January 2025 Spravato prescribing information and recent medical research summaries in its references.
• Applies to: many BlueCross BlueShield of Tennessee members whose pharmacy benefits are administered through CVS Caremark.
• View the complete criteria at BlueCross BlueShield of Tennessee’s Spravato coverage policy used by Spravato clinics when requesting coverage.
• These criteria guide both the first approval and later continuation requests, so clinics track your response and safety over time.

These criteria come from Point32Health’s Spravato guideline and are applied by Harvard Pilgrim and Tufts Health Plan when clinics request coverage. Your clinic checks every item during the evaluation; you do not need to memorize or prove them yourself.

• Age 18 or older with a confirmed diagnosis of major depressive disorder from a qualified mental health specialist.
• For treatment-resistant depression, symptoms remain severe after at least two oral antidepressants at the right dose and duration.
• For suicidal depression, you have major depression with current suicidal thoughts or behavior and need rapid treatment support.
• Depression rating scales such as PHQ-9, HAM-D, MADRS, or similar tools are completed and stored in your chart.
• You tried additional help such as an add-on medication or structured psychotherapy without enough improvement in mood or function.
• You do not have high-risk blood vessel problems, past brain bleeding, or allergies to ketamine or esketamine.
• Treatment happens in a REMS-certified clinic with staff trained to monitor sedation, blood pressure changes, and recovery.

Your clinic’s insurance team handles this entire process after your evaluation and tells you when Point32Health makes a decision so you can schedule treatment.

1. Clinical note confirming diagnosis, severity, treatment goals, and whether treatment is for treatment-resistant or suicidal major depression.
2. Complete list of past antidepressants with names, doses, dates, and your response or side effects for each medication.
3. Details on any add-on medication or structured psychotherapy tried, including timing and proof it did not help enough.
4. Baseline and current depression rating-scale scores, often using PHQ-9, HAM-D, MADRS, or other approved tools.
5. Safety screening notes covering substance use, psychosis, blood pressure issues, and any reason clinic monitoring could be unsafe.
6. Confirmation that dosing and schedule follow the FDA label and Point32Health guidelines, with treatment in a REMS-certified clinic.
7. Submission of the Point32Health Spravato request form or online template used by Harvard Pilgrim and Tufts Health Plan.

Numbers depend on your specific plan design, but this structure will help you talk with the Spravato clinic’s benefits staff. They run a benefits review with Harvard Pilgrim or Tufts Health Plan and walk you through what each visit costs.

• Many members see Spravato billed under the medical benefit as a medical drug given and monitored in the clinic.
• Some plans handle Spravato as a specialty pharmacy drug, shipped to the clinic and paired with separate visit charges.
• You may pay a copay or coinsurance for each visit until you reach your annual deductible and out-of-pocket maximum.
• Early weeks involve two treatments per week, so costs are higher at first and then fall as visits space out.
• Facility, monitoring, and professional fees may post as separate line items from the Spravato medication itself on your statements.
• Use my Spravato insurance cost calculator to estimate costs using your deductible, copays, coinsurance, and out-of-pocket maximum.
• Ask the clinic whether your plan has any visit limits or extra reviews that might change long-term Spravato costs.

Use the numbers on your ID card first, because Point32Health runs many products. These contacts are common starting points for commercial members. Service hours and phone options vary by product, so always follow the guidance printed on your specific card.

• Harvard Pilgrim Member Services for many commercial plans: 888-333-4742, with TTY access through 711 as listed online.
• Tufts Health Plan Member Services for many employer plans: 888-257-1985, with TTY support available through 711 for callers.
• Harvard Pilgrim member portal to check benefits, costs, claims, and plan documents anytime.
• Tufts Health Plan secure member portal to review benefits, claims, ID cards, and coverage details.
• Harvard Pilgrim contact page for alternate numbers, mailing addresses, and help choosing the right department.
• Tufts Health Plan member contact page for plan-specific phone numbers and additional support options.
• Bring your ID card so clinic staff can call, confirm benefits, and review Spravato coverage with you in real time.

This snapshot describes the Spravato guideline your clinic relies on when it requests coverage through Point32Health systems. Harvard Pilgrim and Tufts Health Plan commercial products use aligned criteria posted on the Point32Health medical necessity pages.

• Policy name: Medical Necessity Guidelines, Medical Benefit Drugs – Spravato (esketamine) for CarePartners of Connecticut and related plans.
• Effective date: February 1, 2025, with prior committee reviews and updates through late 2024 documented in the approval history.
• Applies to: Medicare Advantage members and other plans where Point32Health medical benefit drug criteria are used for Spravato coverage decisions.
• Core requirements: adult age, confirmed TRD or suicidal depression, failed antidepressants, rating-scale documentation, and use with an oral antidepressant.
• Coding: lists HCPCS codes S0013, G2082, and G2083 for Spravato dosing and monitoring visits, with coverage tied to meeting criteria.
• View the complete document at Point32Health’s Spravato coverage policy used by clinics when requesting approval.

This section helps you see how closely you match Humana’s detailed medical rules; your clinic confirms every item during your evaluation.

• Age 18 or older with major depressive disorder documented by a depression rating scale such as PHQ-9 or HAM-D.
• Diagnosis is treatment-resistant depression or major depressive disorder with severe suicidal thoughts, matching FDA-approved Spravato uses.
• Poor response or intolerance to at least two antidepressants from different types, each tried long enough at the right dose.
• Spravato given together with an oral antidepressant; no prior full course of ECT, vagal nerve stimulation, or deep brain stimulation.
• No aneurysmal vascular disease, arteriovenous malformation, history of intracerebral hemorrhage, or other serious cerebrovascular risks.
• No active psychosis, uncontrolled substance use disorder, pregnancy, or breastfeeding at the time treatment would begin.
• Care occurs in a REMS-certified clinic where a psychiatrist tracks your depression scores and documents improvement for ongoing approvals.

Your clinic’s insurance and clinical teams handle this entire process after your evaluation; they send Humana the medical proof you qualify.

1. List of your past antidepressants with names, doses, how long you took each, and why they failed or caused issues.
2. Depression rating scale scores, such as PHQ-9 or HAM-D, showing how severe your symptoms were before starting Spravato.
3. Documentation of your current diagnosis, suicide risk if present, and why Spravato is medically appropriate instead of standard options alone.
4. Safety screening results, including blood pressure readings, substance use screening, pregnancy status, and checks for conditions that make Spravato unsafe.
5. Confirmation that a REMS-certified clinic and psychiatrist will supervise dosing, monitoring, transportation rules, and follow-up care after each session.
6. Any required Humana medical or pharmacy prior authorization forms, completed and submitted through Humana’s electronic portals or fax systems.
7. Ongoing progress notes and updated depression scores when Humana asks for re-approvals after the initial treatment period.

These points explain how Humana commercial plans share Spravato costs with you; your exact amounts depend on your specific benefit design and clinic billing practices.

• Many Humana plans cover Spravato under the medical benefit using clinic billing codes that include drug and monitoring time together.
• You may owe a coinsurance percentage for each visit after meeting your deductible, particularly during the first months of treatment.
• If your plan has a copay instead, you pay that fixed amount per session until you hit your out-of-pocket maximum.
• Facility and monitoring fees may be included in one claim, but some clinics add separate evaluation or follow-up visit charges.
• Spravato treatments start twice weekly, then taper to weekly or every other week, so costs fall as sessions spread out.
• Use my Spravato insurance cost calculator to estimate your costs based on deductible, out-of-pocket maximum, and coinsurance.

Use these official Humana resources to confirm your Spravato benefits; always have your member ID card handy when you call or sign in. Ask specifically about coverage for clinic-administered esketamine nasal spray.

• Member Services: Call the number on the back of your Humana ID card for plan-specific Spravato coverage questions.
• TTY for all plans: Dial 711 to reach Humana through your state relay service, then ask for member services.
• Sign in to your Humana member portal to review benefits, deductibles, and prior authorization status.
• Visit Humana’s contact and support page for additional phone numbers, chat options, and mailing addresses.

These details come from Humana’s own coverage library so you and your clinic can see the source your plan uses for decisions.

• Policy name: Spravato™ (esketamine) Nasal Spray pharmacy coverage policy.
• Effective date: July 1, 2025; last reviewed May 21, 2025, according to Humana’s policy index.
• Applies to: many Humana commercial medical and pharmacy plans, with final coverage depending on your specific contract and benefits.
• View the listing and full policy via Humana’s coverage library at Humana’s official Spravato coverage policy.
• Clinics follow instructions in Humana’s prior authorization resources for professionally administered drugs when submitting Spravato requests.

These details come from Molina Healthcare’s national Spravato clinical policy and help you see how clinics match your case to the coverage rules.

• Age 18 or older with major depressive disorder or recurrent major depression, without psychotic features at the time of treatment.
• Depression symptoms measured with rating tools such as PHQ-9, MADRS, HAM-D, or similar scales before and during Spravato treatment.
• For treatment-resistant depression, at least two prior antidepressants from different types failed after six weeks each at the right dose.
• For suicidal depression, you were recently hospitalized or in crisis care and still have severe symptoms even after antidepressant changes.
• No aneurysm, arteriovenous malformation, prior brain bleed, or other serious blood vessel disease that makes Spravato high risk.
• Treatment occurs in a REMS-certified clinic, with staff watching blood pressure and side effects for two hours after dosing.
• Molina requires a psychiatrist or behavioral health specialist to prescribe or closely supervise Spravato and document ongoing benefit for renewals.

After your evaluation, your clinic’s team sends Molina a request for coverage; these are the main pieces they include.

1. List of your past antidepressants, including names, doses, how long you took each, and results or side effects.
2. Depression rating scores, such as PHQ-9 or similar tools, showing how severe symptoms were before starting Spravato treatment.
3. Notes confirming your diagnosis, treatment-resistant pattern or suicidal risk, and why Spravato plus an oral antidepressant is medically needed.
4. Safety checks covering blood pressure, blood vessel risks, substance use, pregnancy status, and other conditions that affect Spravato safety.
5. Confirmation that a REMS-certified clinic will give each dose, watch you on site, and arrange safe transportation after visits.
6. Completed Molina prescription drug prior authorization forms or online requests, which your clinic submits through Molina’s portals or fax lines.
7. Follow-up notes and updated depression rating scores when Molina asks for renewals after the first approval period ends.

Your exact costs depend on your state plan, but these points describe how Molina and your clinic share Spravato expenses.

• Spravato is often billed as a medical benefit, combining the drug, nursing time, and monitoring into a clinic claim.
• Some Molina plans treat Spravato as a pharmacy benefit, with specialty tier cost sharing through contracted pharmacies and clinics.
• Before you meet your deductible, you may pay most visit costs; after that, coinsurance or copays lower your share.
• Once you reach your out-of-pocket maximum, Molina pays covered Spravato costs for the rest of the benefit year.
• Clinics may bill additional facility or observation fees for monitored time, which count toward your deductible and out-of-pocket maximum.
• Use my Spravato insurance cost calculator to estimate your share based on your deductible, coinsurance, and out-of-pocket maximum.
• Early in treatment, Spravato visits are twice weekly, then less often, so monthly costs drop as the schedule spaces out.

Your Molina ID card lists the most accurate phone numbers for your plan; use the details below if you cannot find the card. These resources help you double-check information your Spravato clinic gives you and keep your coverage clear.

• Member Services example line: 1-888-898-7969 (TTY 711), weekdays during business hours; your state plan may list a different number.
• Call Member Services to confirm Spravato coverage, your deductible, coinsurance, and which Spravato clinics or psychiatrists are in network.
• Use the My Molina member portal to view benefits, check claims, and send secure messages.
• Access the My Molina login at member.molinahealthcare.com or through MyMolina.com links on your state’s Molina member website.
• If you still cannot confirm details, ask your Spravato clinic to call Molina directly using its provider or pharmacy contacts.
• For more phone numbers or addresses, use Molina Healthcare contact and support options for your state.

This summary is based on Molina Healthcare’s national Spravato coverage guideline, which many Medicaid, Marketplace, and Medicare plans follow unless a state rule overrides it.

• Policy name: Drug and Biologic Coverage Criteria – Spravato (esketamine).
• Policy number: C16762-A, used across Molina Healthcare lines of business unless a state-specific appendix applies.
• Current effective date: April 4, 2025, with original policy implementation beginning in 2019 and periodic reviews scheduled.
• Applies to: adults with treatment-resistant major depression and adults with major depression plus acute suicidal thoughts or behavior.
• Coverage duration: four weeks for initial approval, then up to six months for treatment-resistant depression when benefit is clearly documented.
• Place of service: non-inpatient hospital or clinic settings able to provide REMS-certified monitoring and emergency support during and after dosing.
• View the complete policy at Molina Healthcare’s Spravato coverage policy, which your clinic uses when submitting authorization and renewal requests.

State-specific appendices may add rules for certain Marketplace or Medicaid products, so clinics always check both this policy and any local guidance.