New Prior Authorization Rules for Esketamine (Spravato) Take Effect May 1, 2025

On May 1, 2025, Texas Medicaid will enforce new prior authorization standards regarding esketamine (Spravato) treatment starting from that date onward. Traditional Medicaid through fee-for-service and managed care organizations known as MCOs will experience direct effects of this modification. The member-specific MCO provides unique administrative procedures that providers need to check because organizations implement different processes.

Expanded Treatment Indications

The enhanced criteria approve esketamine (Spravato) as a solitary treatment for adults from 18 to 80 who have treatment-resistant depression. The expanded guidelines now provide new therapy approaches to help patients who did not succeed with standard treatment methods.

Doctors can find complete Esketamine indications through the Texas Medicaid Provider Procedures Manual Section 6.46 of the Outpatient Drug Services Handbook.

Updated Diagnosis Requirements

The revised criteria extend the list of diagnostic codes for major depressive disorder, for which pharmacy benefits require authorization by providers. These codes are:

Healthcare providers should look at Section 6.46.1 Prior Authorization within the Outpatient Drug Services Handbook for a complete recorded list of accepted diagnosis codes.

Healthcare providers need assistance regarding Esketamine information and must contact the Texas Medicaid & Healthcare Partnership (TMHP) Contact Center through their phone number, 800-925-9126.

Texas Medicaid extends essential depression treatments to its members with treatment-resistant depression through this system update as part of its continuous effort to enhance mental health care throughout the state.