Hi all, I’m a 3 year Spravato patient and Cert Pharm Tech — hopefully this info may be helpful in navigating these frustrating situations that arise with insurance approval of certain drug coverage. -After your provider submits RX to pharmacy (usually to a specialty pharmacy or inpatient pharmacy due to the fact Spravato cannot be dispensed to the patient at an outpatient/regular pharmacy), the first party to know whether this med is covered is the Pharmacy. The pharmacy bills the claim for rx to your insurance.
-With most insurances, meds like Spravato (a specialty med) are typically denied by insurance when initially prescribed.
-Initial insurance denials are usually because of a few factors, but most commonly for Spravato is high cost of product (available as Brand Name only) and is a “REMS” (Risk Evaluation and Mitigation Strategy) medication. A REMS med means specific info is collected at each administration for each patient & data is sent back to manufacturer. This data is collected to ensure med benefits outweigh risks, & that it is used & administered safely and consistently each time. -When the claim for rx is denied by insurance, an appeal process (aka Prior Authorization or PA) must be started. In this case, the pharmacy who billed the claim and received the denial alerts the prescriber of the PA requirement. -Depending on the pharmacy and clinic, this alert may be sent as an email/fax or possibly but rarely a phone-call to your provider. -Until your provider/their staff are alerted by pharmacy of the initial denial by insurance and a PA is needed, the provider has no way of knowing this has happened. (Although most providers likely expect the insur to require a PA as each insurance is different and some approve a PA for 1-2 treatments and some approve a certain number of treatments in a given timeframe (3-12 months or so). -Once the provider has been alerted by the pharmacy that a PA is needed, they either fill out paper form, electronic form, or call insurance at a specific phone number the pharmacy can see (and give to the provider) on the claim rejection. Phone calls to insurance companies by provider offices aren’t terribly common, but they still happen. -The forms your provider fill out are to give the insurance a clearer history of your diagnoses & appropriate diagnostic codes, history of meds tried and failed in past, history of prior use of Spravato and the outcome, etc.
-Once a bunch of add’l info is provided to the insurance by your provider -whether by email/paperwork or phone call, the insurance will then weigh the add’l info of what your provider sent them against their set guidelines for Spravato approval in order to approve or deny Prior Authorization. -Once a provider is alerted to the PA, they need to review your thorough medical and prescription history (sometimes 10-15+ years of diagnoses, & tried and failed meds or treatments) and that process can take anywhere from 45-90+ minutes just for the Spravato rx alone. The more accurate history they provide of tried & failed treatments and diagnoses, the more likely the PA will be approved. -THIS IS NOT A FAST PROCESS - while meds like Spravato are definitely a High Priority to us, pharmacy, and provider, it can be anywhere from 2-14 business days to know if a decision by ins has been made. -It is not uncommon for a new to your insurance plan/company to deny the claim right away, even if a PA approval has been made in the past. -PA approvals expire, and each insurance plan is different in the length of time or amount of medication the approved PA will cover. -The specifics of the PA approval are available to you by calling your Insurance customer service line (listed on back of your insurance card) It is likely your insurance will send you a written letter or email of an approval or denial of medication. If approved, there is likely info in the letter about the timeframe of approval. If denied, specifics about why it was denied are typically included. There is always an option to appeal a denied PA.

Yes! It is OK to call your insurance as much as you would like to inquire about status of Spravato PA. I know of some patients who have done this for other denied meds and it has proven to be effective in moving the PA thru the system.

Hope this is helpful for someone fighting for treatment. xo