Navigating Anthem (Elevance Health) Spravato Prior Authorization

Spravato (Esketamine) and Anthem Coverage Nuances

Spravato, an esketamine nasal spray, is indicated for treatment-resistant depression (TRD) and major depressive disorder with acute suicidal ideation or behavior. As a specialty medication with specific administration requirements, its prior authorization process with Anthem-licensed plans involves considerations across medical and behavioral health benefits, often managed through Carelon Behavioral Health or CarelonRx.

Anthem (Elevance Health) Spravato PA Submission Channels

• **Behavioral Health Services:** For many Anthem lines, behavioral health services, including Spravato, are managed through Carelon Behavioral Health. Providers must verify the specific carve-out or in-network handling per line of business and state.
• **Medical Benefit (Administration):** If Spravato administration falls under the medical benefit, submissions may route through Availity Essentials, Anthem's primary multi-payer provider workspace. X12 278 transactions are accepted via clearinghouses.
• **Pharmacy Benefit (Drug):** If Spravato is covered under the pharmacy benefit, prior authorization is managed by CarelonRx (Anthem's in-house PBM) and can be submitted via CoverMyMeds or Surescripts ePA.
• **Carelon MBM:** While Spravato is not typically routed through Carelon Medical Benefits Management, it is crucial to verify the specific domain scope for any related services, as their submission pathway is distinct.

Accessing Spravato Utilization Management Policies

Anthem operating companies publish medical policies and clinical UM guidelines through provider sites accessible via Availity. For Spravato, providers should consult policies related to behavioral health, specialty pharmacy, and medical necessity criteria. Policies may reference Anthem-developed, Carelon-developed, MCG-based, or NCCN-compendium-based criteria, with state-specific Medicaid and Medicare Advantage variants.

Frequent Denial Categories for Spravato with Anthem

• **Medical Necessity / Insufficient Documentation:** Lack of comprehensive clinical notes supporting TRD diagnosis or failure to meet step therapy requirements.
• **Step Therapy Not Completed:** Failure to demonstrate trials of prerequisite antidepressant medications as outlined in Anthem's clinical guidelines.
• **Site-of-Service Mismatch:** Discrepancies between the proposed administration setting and Anthem's site-of-care policies for specialty medications.
• **Non-Formulary / Benefit Grid Issues:** Spravato not covered under the specific state-plan benefit grid or classified as non-formulary under the pharmacy benefit.
• **Behavioral Health Carve-Out:** Incorrect submission channel due to behavioral health services being managed by a separate entity (e.g., Carelon Behavioral Health).

Anthem (Elevance Health) Spravato Appeal Process

Denied Spravato prior authorizations can be appealed through the Anthem operating-company appeals process, detailed in the provider manual. If the denial originated from Carelon Behavioral Health, their specific appeal pathway must be followed. Peer-to-peer (P2P) reviews are available for both medical and behavioral health denials, offering an opportunity for direct clinical discussion with an Anthem or Carelon medical director.

Electronic PA and Interoperability with Anthem

Elevance Health, through its Anthem operating companies, has participated in Da Vinci Project initiatives, including HL7 connectathons. While specific conformance status requires verification, the broader ecosystem supports electronic PA. For pharmacy benefit Spravato, ePA is available via CoverMyMeds and Surescripts. X12 278 transactions are a supported channel for medical benefit PAs.