Referring a Patient to Esketamine: Criteria, Documents and the Path, Country by Country

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This page is for clinicians considering an esketamine referral, and it answers the three questions that actually decide one: does this patient meet the payer's criteria (not just the label), what must the referral file contain, and where does the referral go. It compares the four systems our readers ask about most, Germany, the United Kingdom, Poland and Switzerland. It is an informational summary, not clinical guidance: indications and treatment decisions remain with you and your national guidelines. The patient-facing version of this path, for the person you are referring, is our access overview; the full 17-country payer table lives on the reimbursement map.

The label everyone shares

The EU marketing authorisation is the common floor: esketamine nasal spray, in combination with an SSRI or SNRI, for adults with a current moderate-to-severe major depressive episode that has not responded to at least two different antidepressants at adequate dose and duration within that episode (EMA EPAR). Three phrases in it decide most borderline referrals. "Adequate dose and duration": a drug stopped at week two for side effects is generally not a failed trial, and most payers count treatments taken at adequate dose for at least four to six weeks. "Within the current episode": prior-episode failures do not automatically count. "Two different antidepressants": two substances, not two doses of one.

What sits on top of that floor is national, and it is where referrals succeed or stall.

Germany: the label is the rule

The GKV reimburses along the authorisation, with no pre-approval procedure for in-label outpatient use and no variation between sickness funds. Two decisions make the German route unusually stable for the prescriber: the G-BA's finding of "considerable added benefit" (2023), and a nationwide Praxisbesonderheit that keeps Spravato prescriptions out of the practice budget. If a colleague declines with a budget argument, that agreement is the answer. Office-based practices bill the supervised administration and the roughly two-hour observation via GOP 01549. Initiation is psychiatrist-led; the practical constraint is observation capacity, not funding, so the referral goes to a practice or outpatient unit that actually administers, listed for Germany here.

United Kingdom: one medicine, two answers

Scotland accepts esketamine for its revised indication via SMC2258, with documented TRD (no response to at least two antidepressants in the current episode) and a Patient Access Scheme; local NHS board arrangements govern actual access. England and Wales are different: NICE declined to recommend routine use, and TA854 protects existing funding arrangements rather than opening new ones, so new NHS starts are exceptional and the practical route south of the border is private or a clinical trial. Calling England "private-only" is a slight simplification, but it is the planning assumption that will not mislead your patient. Details and the private landscape: UK access guide.

Poland: a funded programme with its own corridor

Poland funds esketamine fully, free to the patient, through NFZ drug programme B.147. The corridor is specific: ages 18 to 75, and at least two but no more than five failed antidepressant treatments in the current episode, a ceiling that surprises referrers trained on "the more failures, the stronger the case". Enrolment is possible at any contracted centre nationwide (around 64), and a live national waiting-time portal shows queues per centre, worth checking before you pick one. Centres and their registry records: Poland listings.

Switzerland: the strictest gate, precisely specified

Since October 2025 the basic insurance (OKP) reimburses esketamine, under the tightest criteria of the four: ages 18 to 74, failure of two antidepressants plus one augmentation strategy, illness severity of CGI-S 5 or higher, treatment only at one of the 52 BAG-designated centres, and only after the insurer's trust doctor (Vertrauensarzt) approves a cost request (Kostengutsprache), for a maximum of 10 months, extendable twice by three. For the referring clinician this means two things: the augmentation attempt must be documented, not just recalled, and the cost request is where under-documented files die quietly. The referral file below is, in Switzerland, literally the application.

The referral file that gets accepted

Across all four systems the same core file decides speed, and in pre-approval systems it is what the payer's physician reads. In the words of one of this directory's medical reviewers: "What convinces an evaluating doctor is not the number of drugs listed but the quality of each entry. For every prior antidepressant I want to see the substance, the highest daily dose actually reached, how long it was taken at that dose, and what happened, ideally with a before-and-after score such as PHQ-9 or MADRS rather than a sentence. The reason for stopping matters: a drug dropped after two weeks for side effects is not a failed trial. One signed, dated page from the treating psychiatrist with the discharge letters attached does more than a thick folder." (Dr. Grischa Judanin, MD)

The one-page checklist, printable from our clinician hub: diagnosis and episode course with severity scores and dates; each antidepressant of the current episode with substance, maximum dose, weeks at dose, measured outcome, adverse effects, reason for discontinuation; augmentation attempts in the same format (mandatory detail for Switzerland, and for the Polish ceiling count); psychotherapy with modality and duration; psychosis and bipolar screening; blood pressure and cardiovascular status against the label's contraindications; complete current medication; substance-use history and current risk assessment.

Where applications stall, predictably

Inadequate trials counted as failures. The commonest correction at assessment: short or sub-dose courses do not count, and the application gets re-counted downward below threshold.

Prior-episode failures counted in. The label and every payer criterion here are episode-bound.

Missing augmentation documentation. Fatal in Switzerland, relevant in several other European systems (the Netherlands and Spain also require it); if augmentation was tried, document it like a drug trial.

The Polish ceiling. More than five documented failures in the episode excludes B.147 funding; patients with long histories need the episode boundary drawn carefully.

No administering site found. Funding does not create capacity. Our directory lists administering centres per country with registry verification and a last-checked date: Germany, UK, Poland, Switzerland. Patients can arrive at the first appointment pre-screened via our eligibility check, which produces a written summary of the treatment history in exactly the structure above.

Sources

1. EMA: Spravato EPAR and product information
2. G-BA: considerable added benefit finding (2023)
3. Nationwide Praxisbesonderheit for esketamine nasal spray
4. KV Berlin: GOP 01549 billing of the observation period
5. SMC2258: esketamine accepted for restricted use in Scotland
6. NICE TA854: esketamine for treatment-resistant depression
7. NFZ waiting-time portal (programme centres, Poland)
8. BAG: limited medical use and designated centres, Switzerland

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Informational summary for clinicians, not clinical guidance; indications, contraindications and treatment decisions belong with the treating physician and national guidelines. Payer criteria as verified on the dates shown on the reimbursement map; rules change, check the primary source before relying on a threshold.