SPRAVATO® Implementation Inquiry Form Clinic Name * Point of Contact First Name Last Name Email * Practice Type * Private Practice, Primary Care Private Practice, Psychiatry Community Health Center Rural Health Clinic Hospital Outpatient Clinic Telehealth Only Other Patient Panel Size Less than 500 patients 500–1,000 patients 1,000–2,500 patients More than 2,500 patients Number of Patient Rooms Available for SPRAVATO Therapy 1–2 rooms 3–5 rooms More than 5 rooms Contracted Insurance Providers Commercial - Aetna Commercial - BCBS New Mexico Commercial - Centene Corporation Commercial - Cigna Commercial - Humana Commercial - Molina Healthcare Commercial - Presbyterian Healthcare Services Commercial - United Healthcare Commercial - Western Sky Community Care Medicare Advantage - Aetna Medicare Advantage - Anthem Medicare Advantage - BCBS New Mexico Medicare Advantage - Cigna Medicare Advantage - Humana Medicare Advantage - Medica Health Plans Medicare Advantage - Tufts Health Plan Medicare Advantage - UPMC Health Plan Medicare Part D - BCBS Federal Employee Plan Medicare Part D - Cigna Medicare Part D - Clear Spring Health Medicaid/Managed Medicaid - Molina Healthcare Medicaid/Managed Medicaid - Presbyterian Healthcare Services Medicare-Medicaid Dual Eligibility - Anthem Medicare-Medicaid Dual Eligibility - BCBS New Mexico Other - BCBS Federal Employee Plan (Federal Employer) Other - Department of Veterans Affairs Health Plan (Veterans Affairs) We Do Not Accept Insurance Does your clinic have experience with buy-and-bill insurance models? Yes No I don't know Have you administered other REMS-certified treatments before? Yes No I don't Know Are you familiar with the Risk Evaluation and Mitigation Strategy (REMS) requirements for SPRAVATO®? Yes No Does your clinic currently have the capacity to monitor patients for two hours post-treatment? Yes No Not Sure Are you currently treating patients with treatment-resistant depression? Yes No Not Sure If yes, approximately how many TRD patients are in your clinic’s care? Fewer than 10 10–50 More than 50 Not Sure Not Applicable Goals for SPRAVATO® Implementation Expand treatment options for patients with treatment-resistant depression Improve patient access to innovative therapies Increase clinic revenue Meet growing demand for mental health treatments Train staff on innovative mental health treatments Build partnerships for collaborative care Other Preferred Consultation Format Virtual Meeting On-Site Visit Email Follow-Up Call Additional Information or Questions Thanks for Getting in Touch!We’re grateful you’re interested in working with us to make SPRAVATO® accessible.We’ll review your details and reach out within 3 business days.In the meantime, if anything comes up, feel free to connect with us directly. We’re looking forward to taking the next steps together.Thanks for being part of something that matters.
