Spravato denied as non-formulary by Aetna?

Aetna's specific coverage criteria for spravato are defined in its own published medical/coverage policy and the FDA-approved prescribing label. A successful appeal documents that your medical records satisfy each criterion those sources list — confirmed diagnosis, any required prior treatments (with dates and outcomes), and clinical severity. If the exact criteria weren't included with your denial, request them in writing; your appeal then maps each requirement to the matching fact in your chart.

## Why Aetna May Deny Spravato as Non-Formulary

A non-formulary denial for esketamine nasal spray (Spravato) means the drug is either excluded from Aetna's drug benefit formulary for your specific plan, or is placed on a tier that requires additional authorization before coverage. For Spravato — which is only available through a REMS-certified healthcare setting and cannot be dispensed at a retail pharmacy — non-formulary status is common because specialty drugs administered in clinical settings are handled under the medical benefit by some plans and the pharmacy benefit by others. Misrouting the request to the wrong benefit is a frequent and correctable source of denial.

## Federal Appeal Framework

• Internal appeal (ACA §2719 / ERISA §503): File within the window on your Explanation of Benefits. Aetna must respond within 30 days (prospective) or 60 days (post-service).
• Exception process: Before a full appeal, request a formulary exception. Most plans must grant an exception when a formulary alternative is contraindicated, not tolerated, or clinically inferior for the specific patient. A prescriber's letter supporting the exception is required.
• External review: If the internal appeal and any exception request are denied, IRO external review is available, typically within four months of the final adverse internal determination.
• Expedited track: Available (72-hour turnaround) when clinical urgency warrants it.

## Documentation to Gather

1. Benefit-routing verification: Confirm with Aetna whether Spravato should be processed under the pharmacy benefit or medical benefit for your plan. Obtain the correct prior-authorization request form for the applicable benefit. 2. Formulary-exception letter: Prescriber letter explaining why each covered formulary alternative is clinically inappropriate for this patient — citing documented intolerances, treatment failures, or the specific FDA-approved indication that is not covered by alternatives. 3. Diagnosis and severity records: Psychiatric documentation supporting the specific diagnosis and the clinical need for this drug rather than a formulary agent. 4. Prior-treatment history: Dates and outcomes for each formulary or covered alternative that was tried, if any were. 5. REMS documentation: Confirmation that the prescribing site is a REMS-certified healthcare setting, which may be required by Aetna to process the claim under the correct benefit category.

## Criteria-Mapping Structure

Obtain Aetna's formulary for your specific plan and their esketamine medical policy. In your appeal letter, address each reason the non-formulary denial was issued. If the denial was for lack of a prior authorization, include the completed authorization request with supporting records. If the denial was for exclusion, address each alternative the plan considers covered and explain in writing why each is clinically inadequate for this patient.