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TRICARE East Spravato Continued Treatment Form

Humana Military requires a new authorization to continue Spravato (esketamine) nasal spray for TRICARE East patients, and this five-page form documents the response so far. The provider reports rating scale outcomes, including whether symptoms improved by 50% or more, medication changes, suicide attempts and substance use since starting, adherence, and a clinical progress summary with the dosing plan.

Who completes it

The rendering or ordering provider completes the beneficiary, rendering and ordering provider details, clinical history, progress summary and exclusions checklist, 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 beneficiary must stay enrolled in the Spravato REMS program and be monitored for at least two hours after each dose by a qualified health care provider.
  • Indications are treatment-resistant depression in adults (12 doses over eight weeks) or major depressive disorder with acute suicidal ideation or behavior with an oral antidepressant (eight doses over four weeks).
  • The checklist flags vagal nerve or deep brain stimulation, a full ECT course this episode, aneurysmal vascular disease, arteriovenous malformations, intracerebral hemorrhage, active psychosis and pregnancy.
  • The form asks whether criteria for substance use disorder were met in the last 90 days and whether TMS will be given during Spravato treatment.

Get the official form

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

Spravato Nasal Spray continued treatment authorization 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 improvement does TRICARE look for to continue Spravato?

The form asks for evidence-based rating scale outcomes, with dates and scores, supporting the major depressive disorder diagnosis, and whether there was a 50% or greater improvement on standardized rating scales. A clinical progress summary covers treatments to date, response, impact on symptoms and functioning, and the dosing plan.

How is Spravato billed under TRICARE?

Humana Military's form states that TRICARE limits Spravato treatment reimbursement to codes G2082 and G2083 and restricts provider reimbursement to the buy-and-bill model. Units and frequency for each code are entered in the service request section with the continued treatment date.

Which form starts Spravato treatment under TRICARE East?

The separate Spravato initial authorization form. The continued treatment form applies once treatment is underway and adds questions about medication changes and suicide attempts since the initial Spravato treatment, plus the number of treatments given to date.