Use the correct HCPCS code for Spravato^®

Use the correct HCPCS code when requesting prior authorization or billing for Spravato (esketamine).

• Use S0013 for dates of service on or after Jan. 1, 2021.
• Use J3490 or J3590 for dates of service prior to Jan. 1, 2021.

We first communicated about this in the article titled HCPCS replacement codes established, in the March 2021 issue of The Record.

The Centers for Medicare & Medicaid Services, or CMS, established the permanent HCPCS code of S0013 for this medical benefit drug to be used for dates of service on or after Jan. 1, 2021. However, many providers are using the older codes for these newer dates of service. This has resulted in problems with reimbursing claims.

Prior authorization information

Providers must request prior authorization for Spravato when it is administered in outpatient settings for:

• Members covered through Blue Cross commercial fully insured groups except for groups that have opted out of the prior authorization program
  Note: For groups that have opted out of the prior authorization program, Spravato is covered for the FDA approved indications.
• Blue Cross commercial members with individual coverage
• Medicare Plus Blue^SM members
• BCN commercial members
• BCN Advantage^SM members

Additional information

For more information on requirements related to drugs covered under the medical benefit, see the following documents:

• For commercial members, see the Blue Cross and BCN utilization management medical drug list for Blue Cross PPO (commercial) and BCN HMO (commercial) members (PDF) document.
• For Medicare Advantage members, see the Medical Drug and Step Therapy Prior Authorization List for Medicare Plus Blue PPO and BCN Advantage members document.

Posted: May 2021
Lines of business: Blue Cross Blue Shield of Michigan and Blue Care Network