Getting Spravato (esketamine nasal spray) requires meeting specific medical criteria, finding a certified treatment center, and navigating insurance approval. You cannot pick it up at a pharmacy or use it at home. Every dose must be administered at a healthcare facility enrolled in a federal safety program, which makes the process more involved than a typical prescription. Here’s what each step looks like.
Who Qualifies for Spravato
Spravato is FDA-approved for two conditions. The first is treatment-resistant depression in adults, meaning you’ve tried at least two different antidepressants at adequate doses and durations during your current depressive episode without meaningful improvement. The second is major depressive disorder with active suicidal thoughts or behavior, where it’s used alongside an oral antidepressant.
Certain medical conditions disqualify you entirely. You cannot receive Spravato if you have an aneurysm anywhere in your body (including the aorta or brain), an arteriovenous malformation, a history of bleeding in the brain, or an allergy to esketamine or ketamine.
Step 1: Talk to a Prescriber
Start with a psychiatrist or the provider managing your depression. They’ll evaluate whether your treatment history meets the threshold for treatment-resistant depression. That generally means you’ve had an inadequate response to at least two antidepressants from different classes (for example, an SSRI like sertraline and an SNRI like venlafaxine), each taken at a therapeutic dose for at least six weeks during your current episode. If your situation involves acute suicidal ideation, the qualifying criteria are different and your provider can assess that directly.
Not every psychiatrist prescribes Spravato. If yours doesn’t, ask for a referral to a provider at a certified treatment center.
Step 2: Find a Certified Treatment Center
Spravato can only be given at healthcare settings enrolled in the Spravato REMS (Risk Evaluation and Mitigation Strategy) program. This is a federal safety requirement, not optional. The manufacturer maintains a searchable directory at spravato.com where you can look up certified locations by ZIP code or city. These are typically psychiatry offices, hospital outpatient clinics, or specialized ketamine/esketamine clinics that have completed the certification process and trained their staff on the required monitoring protocols.
Step 3: Get Insurance Authorization
Nearly all insurers require prior authorization before covering Spravato. This is where the process often slows down. Your prescriber’s office will submit documentation to your insurance company proving you meet the clinical criteria. Based on a representative policy from Cigna, typical requirements include proof that you showed less than 25% improvement in depression symptoms after trying at least two antidepressants from different drug classes, each at a therapeutic dose for a minimum of six weeks.
Your provider’s office usually handles the paperwork, but you can help by keeping records of every antidepressant you’ve tried, the dose, how long you took it, and why it was stopped. If your initial authorization is denied, most insurers have an appeals process. Some treatment centers also have staff dedicated to navigating prior authorizations and can guide you through it.
For patients without insurance or whose insurance denies coverage, Janssen (the manufacturer) offers a savings program. Eligibility and out-of-pocket costs vary, so contact the treatment center or the Spravato website directly for current details.
What the REMS Enrollment Involves
Before your first dose, you’ll formally enroll in the REMS program. This is a brief process that happens at your treatment center. You’ll complete a patient enrollment form with your provider and receive counseling about the two main risks the program is designed to manage: sedation and dissociation (a feeling of being detached from your body or surroundings). This enrollment is a one-time step, though you’ll receive counseling again before every subsequent dose.
What Treatment Days Look Like
Each Spravato session takes about two and a half hours. You’ll self-administer the nasal spray under the direct observation of a healthcare provider, then remain at the facility for at least two hours of monitoring. During that time, staff will check your blood pressure and watch for sedation, dissociation, or other side effects. You won’t leave until your provider determines you’ve recovered sufficiently.
The treatment schedule follows three phases. During the induction phase (weeks 1 through 4), you’ll go in twice a week. In weeks 5 through 8, sessions drop to once a week. From week 9 onward, most patients move to once every two weeks, though some continue weekly based on their response.
Plan to block out your entire afternoon or morning for each session. You cannot drive, operate machinery, or do anything requiring full alertness until the next day after a restful sleep. You’ll need someone to drive you home from every appointment.
Practical Tips to Speed Up the Process
- Document your medication history now. Write down every antidepressant you’ve taken, including doses and approximate dates. This is the single most important piece of information for both your prescriber and your insurance company.
- Search for a treatment center early. Availability varies by region, and some centers have waitlists. Use the locator at spravato.com while you’re still working with your prescriber on authorization.
- Ask about scheduling flexibility. Twice-weekly sessions during induction can be hard to manage around work. Some centers offer early morning or late afternoon slots. Since you can’t drive afterward, arranging reliable transportation in advance will save you stress.
- Be prepared for the prior authorization timeline. Approval can take anywhere from a few days to several weeks. If you’re denied, ask your provider’s office to file an appeal with additional clinical documentation.
How Long Before You Know If It’s Working
Some patients notice improvement within hours or days of their first dose, which is one of Spravato’s distinguishing features compared to traditional antidepressants that take weeks to build up. However, the full induction phase runs four weeks, and your provider will assess your response throughout that period before deciding on a long-term maintenance plan. If you don’t see meaningful benefit after the induction phase, your provider will discuss whether to continue or explore other options.