Spravato

Generic: esketamine hcl nasal

140 MG — Nasal Spray

Also known as: SPRAVATO SOL 56MG DOS SPRAVATO SOL 84MG DOS Spravato 56Mg Dose Spravato 84Mg Dose SPRAVATO 56MG DOSE SOPK 28MG/DEVICE SPRAVATO 84MG DOSE SOPK 28MG/DEVICE

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Coverage by Insurer

Informational only — Coverage rules change frequently; verify tier placement and restrictions with your plan or pharmacy before acting.

Blue Cross Blue Shield Federal

2 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 15 hours, 16 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBS Federal Basic Option 2026	Tier 3 - Non-Preferred Brand	✓	—	—	PA
BCBS Federal Standard Option 2026	Tier 3 - Non-Preferred Brand	✓	—	—	PA

Blue Cross Blue Shield of NC

5 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 15 hours, 16 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
BCBSNC Blue Care 2026	Tier 5 - Specialty	✓	—	✓	PA \| QL
BCBSNC Blue Value 2026	Tier 5 - Specialty	✓	—	✓	PA \| QL
BCBSNC Blue Advantage 2026	Tier 5 - Specialty	✓	—	✓	PA \| QL
BCBSNC Blue Home with UNC Health Alliance 2026	Tier 5 - Specialty	✓	—	✓	PA \| QL
BCBSNC Blue Local 2026	Tier 5 - Specialty	✓	—	✓	PA \| QL

NC State Health Plan

3 plans

Source: PDF · Formulary date: Oct 1, 2026 · Checked: 15 hours, 16 minutes ago

Plan	Tier	Prior Auth	Step Therapy	Quantity Limit	Restrictions
NC State Health Plan - 70/30 Standard PPO 2026	Tier 3 - Non-Preferred Brand	✓	—	—	PA
NC State Health Plan - HDHP 2026	Tier 3 - Non-Preferred Brand	✓	—	—	PA
NC State Health Plan - 80/20 Plus PPO 2026	Tier 3 - Non-Preferred Brand	✓	—	—	PA