Spravato Referral Form

Thank you for considering referring your client to iTrust Wellness Group. Your trust means a great deal to us. In both clinical trials and our office’s experience, Spravato treatment has produced significant results in the provision of relief from symptoms of major depressive disorder. For patients whose lives have been drastically impacted by this diagnosis and who have struggled to find efficacious treatment, Spravato can be a life-changing choice.

 

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How To Schedule a Consult for Your Client:

FDA indication: Patients with a diagnosis of major depressive disorder who have not responded to at least 2 antidepressant trials of adequate dose and duration are candidates for referral for Spravato (esketamine).

1. Our office will require a referral including demographic/insurance information, appointment notes, and a clinical summary of care that includes the recommendation for Spravato. This will greatly help expedite the referral and insurance approval process.

 

2. We require a Benefits Investigation be submitted before the Spravato consultation at our office. The Benefits Investigation will tell us if the client’s pharmacy benefits are willing to cover the medication. We want to make sure this is financially feasible before moving forward. Once the medication is approved, we will call the patient to schedule a Spravato consultation. We will notify your office if we are unable to move forward.

  • For this Benefits Investigation Form, Janssen CarePath requires the client’s signature on the very last page. The client can sign at their appointment date in your office or at their convenience. To expedite the process we ask that you or the client also complete sections 3 and 6. Once receiving this paperwork back (by fax or uploading it to the referral), our staff will complete the rest and send it off.

  • After we are able to send off the Benefits Investigation Form, your client will receive an email from the REMS (Risk Evaluation and Mitigation Strategy) program asking for their electronic signature. 

  • Please inform your client to expect a call from our office (864-520-2020) confirming details and to explain further processes.

(Need Client's Signature)

Location:

117 Commons Way

Greenville, SC 29611

Phone: 864.520.2020

Fax: 864.640.4400

© 2019 by iTrust Wellness Group, LLC

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