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TRICARE East Spravato Initial Authorization Form

Before a TRICARE East patient starts Spravato (esketamine) nasal spray, Humana Military needs this four-page initial authorization request from the treating site. It documents the onset of the current depressive episode, psychiatric diagnoses, current and past medication trials with dose ranges and responses, adherence, rating scale outcomes, prior psychotherapy and Spravato, and a checklist of exclusions.

Who completes it

The rendering or ordering provider at a Spravato REMS-certified site completes the whole form, including the reason for initial treatment, and signs it.

Submitting and payment

How to submit it
Type it in the fillable fields rather than by hand and submit it through Humana Military provider self-service; fax only if online submission is not possible.
Who pays
TRICARE limits Spravato reimbursement to codes G2082 and G2083, and provider reimbursement is restricted to the buy-and-bill model.

Good to know

  • The provider confirms the beneficiary agrees with treatment goals, will be enrolled in REMS, and will be monitored for at least two hours after each administration.
  • Psychiatric medication history asks for each trial's dose range or titration, start and stop dates, response, reason for discontinuation and compliance.
  • Exclusions include recent vagal nerve or deep brain stimulation, a full ECT course this episode, aneurysmal vascular disease, intracerebral hemorrhage history, active psychosis, pregnancy and esketamine or ketamine hypersensitivity.
  • The form asks whether criteria for substance use disorder were met in the last 90 days. Continued treatment later uses the separate Spravato continued treatment form.

Get the official form

Download the current version from the source each time; forms change without notice.

Spravato (Esketamine) therapy initial request form

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

What does TRICARE need to start Spravato?

Humana Military's initial form asks for the depressive episode onset, diagnoses with ICD-10 codes, current medications and past antidepressant trials, documented adherence, rating scale outcomes, psychotherapy and Spravato history, substance use in the last 90 days, the reason for treatment, REMS enrollment and two-hour post-dose monitoring.

Which conditions are flagged on the TRICARE Spravato form?

Vagal nerve or deep brain stimulation, or a full ECT course of at least seven treatments, in the current episode; aneurysmal vascular disease; arteriovenous malformations; intracerebral hemorrhage history; active psychosis; pregnancy or breastfeeding; hypersensitivity to esketamine or ketamine; and planned TMS during Spravato treatment.

Can the Spravato request be handwritten?

Humana Military asks providers to complete the entire form using the fillable fields and avoid handwritten submissions, to ensure timely processing and avoid delays or denials. Once complete, the form is submitted through provider self-service.