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Washington F252-135-000: Esketamine Nasal Spray Request

Washington prescribers request workers' compensation coverage of esketamine nasal spray for treatment-resistant depression with this two-page form, new in September 2026. An initial 6-week trial requires accepted or authorized major depressive disorder, failed antidepressants, augmentation and ECT or TMS, a moderate to severe PHQ-9 or MADRS score within 30 days, REMS certification and screening for listed contraindications.

Who completes it

The prescribing provider completes section 1, then section 2 for an initial trial or section 3 for continued coverage, and signs section 4.

Submitting and payment

How to submit it
Fax it with supporting medical documentation to L&I's Office of the Medical Director at the number on the form, with the claim number written on every page.
Who pays
The form lists no billing code; it decides whether the insurer covers the nasal spray on the claim.

Good to know

  • Failed trials must include at least three antidepressants from different classes, one augmenting agent (second-generation antipsychotic, lithium or thyroid supplementation), and either ECT or TMS.
  • Continued coverage needs meaningful improvement, at least 6 points on PHQ-9 or 10 points on MADRS, good tolerance and dosing consistent with FDA labeling.
  • The provider confirms no current or past aneurysmal vascular disease, arteriovenous malformation, intracerebral hemorrhage, psychosis or substance use disorder, and that other cautions are addressed.

Get the official form

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

Esketamine Nasal Spray for Treatment-Resistant Depression

Official pagePDF

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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 L&I require for an esketamine trial?

All of the initial criteria: major depressive disorder accepted or treatment authorized; failed trials of three antidepressants from different classes, an augmenting agent, and ECT or TMS; a PHQ-9 of 10 or more or MADRS of 20 or more within 30 days; REMS certification; and screening for the listed contraindications.

How is esketamine coverage continued on a Washington claim?

After the initial 6-week trial, complete section 3: show at least a 6-point PHQ-9 or 10-point MADRS reduction from baseline with dates and scores, confirm the spray was well tolerated without significant adverse outcomes, and confirm dosing is consistent with FDA labeling.