ESKETAMINE

ESKETAMINE (14794P)

esketamine 28 mg/2 actuations nasal spray, 2 x 2 actuations
14794P
Body System:
Manner of administration:Nasal
General Schedule
Authority Required

Restriction

Indication: Treatment resistant major depression
Treatment phase: Non-induction treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 8 # of repeats: 5 DPMQ: $2,494.66 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Spravato

ESKETAMINE (14813P)

esketamine 28 mg/2 actuations nasal spray, 2 x 2 actuations
14813P
Body System:
Manner of administration:Nasal
Public
S100 HSD Public
Authority Required

Restriction

Indication: Treatment resistant major depression
Treatment phase: Induction treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 8 Max qty units: 16 # of repeats: 0 DPMQ: $4,706.56 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Spravato

ESKETAMINE (14814Q)

esketamine 28 mg/2 actuations nasal spray, 2 x 2 actuations
14814Q
Body System:
Manner of administration:Nasal
Private
S100 HSD Private
Authority Required

Restriction

Indication: Treatment resistant major depression
Treatment phase: Non-induction treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 8 # of repeats: 5 DPMQ: $2,407.66 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Spravato

ESKETAMINE (14815R)

esketamine 28 mg/2 actuations nasal spray, 2 x 2 actuations
14815R
Body System:
Manner of administration:Nasal
General Schedule
Authority Required

Restriction

Indication: Treatment resistant major depression
Treatment phase: Induction treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 8 Max qty units: 16 # of repeats: 0 DPMQ: $4,875.02 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Spravato

ESKETAMINE (14831N)

esketamine 28 mg/2 actuations nasal spray, 2 x 2 actuations
14831N
Body System:
Manner of administration:Nasal
Private
S100 HSD Private
Authority Required

Restriction

Indication: Treatment resistant major depression
Treatment phase: Induction treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 8 Max qty units: 16 # of repeats: 0 DPMQ: $4,760.94 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Spravato

ESKETAMINE (14837X)

esketamine 28 mg/2 actuations nasal spray, 2 x 2 actuations
14837X
Body System:
Manner of administration:Nasal
Public
S100 HSD Public
Authority Required

Restriction

Indication: Treatment resistant major depression
Treatment phase: Non-induction treatment
Quantities & Cost
Max qty packs Max qty units # of repeats DPMQ Max safety net General Patient Charge
Max qty packs: 4 Max qty units: 8 # of repeats: 5 DPMQ: $2,353.28 Max safety net: $25.00 General Patient Charge: $25.00
Available brands
Spravato