UM Clinical Guidelines — Spravato® (esketamine nasal spray) PAM–021

Iowa Medicaid program:

Prior authorization

Effective date:

Revision number:

4

Last Rev date:

6/27/2024

Reviewed by:

Medicaid Medical Director

Next rev date:

Approved by:

Approved date:

Overview

Medication:¹     

esketamine 

Brand name: 

Spravato^® 

Pharmacologic category: 

N-methyl-D-aspartate (NMDA) receptor antagonist.