While Spravato® is now an FDA-approved treatment, it is a form of ketamine, making its insurance approval process complicated. So, is Spravato® covered by insurance? The answer is yes, most major insurance plans provide coverage for Spravato® (esketamine) treatment, though specific requirements and approval processes vary by provider. Medicare Part B typically covers 80% of treatment costs, as Spravato must be administered in clinical settings. Meanwhile, major commercial insurers, including Blue Cross Blue Shield, Aetna, Cigna, UnitedHealthcare, and Tricare, all offer coverage for qualified patients. Medicaid programs generally cover Spravato as well, though coverage depends on state-specific formularies and meeting clinical criteria.
However, obtaining insurance coverage for Spravato requires meeting strict clinical and administrative requirements across all plans. Patients must have a confirmed diagnosis of treatment-resistant depression or major depressive disorder with suicidal ideation, demonstrate inadequate response to multiple traditional antidepressants, and obtain prior authorization from their insurance provider.
Most insurers also require that treatment be administered only at certified healthcare facilities. Coverage may also be excluded for patients with moderate to severe substance use disorders, and some plans have age restrictions or require specific documentation of previous treatment failures before approving coverage.
Do Most Health Insurance Plans Cover Spravato Treatment for Depression?
Most major health insurance plans do cover Spravato treatment for depression, but with significant restrictions and requirements that can make approval challenging. However, most doesn’t mean coverage is easy to obtain. Insurance plans will not cover Spravato for diagnoses other than treatment-resistant depression (TRD) or major depressive disorder (MDD) with acute suicidal ideation. This criterion creates a significant barrier since patients must first demonstrate failure with multiple traditional antidepressants and meet strict diagnostic criteria.
All insurance plans for ketamine-infusion therapy require prior authorization, treatment must be administered only in certified facilities that comply with FDA safety requirements, and coverage may be denied for patients with substance use disorders. While insurance coverage is available across the major payers, the approval process is rigorous and requires extensive documentation, with additional manufacturer support programs available to help reduce patient costs.
Does Medicare Cover Spravato® Treatment for Depression?
Yes, Medicare will cover Spravato treatments if your doctor has recommended it. Medicare Part B covers esketamine because it cannot be self-administered and must be given in a clinical setting, making Part B coverage extremely important due to the high cost of this drug. This is different from regular ketamine treatments, which Medicare does not cover for mental health issues. Still, Medicare may cover Spravato, which contains esketamine, an FDA-approved drug that derives from ketamine for treatment-resistant depression.
Important Coverage Details:
- Part B Coverage: Spravato falls under Medicare Part B (not Part D) because healthcare professionals must administer it in certified clinical settings
- Cost Structure: Medicare Part B typically covers 80% of approved costs after you meet your deductible, leaving you responsible for 20% coinsurance
- Medical Necessity: Coverage requires that your doctor determine the treatment is medically necessary for your condition
- Approved Conditions: Coverage is specifically for FDA-approved uses, primarily treatment-resistant depression and major depressive disorder with acute suicidal ideation
Requirements for Coverage:
- Must be prescribed by a qualified healthcare provider
- Treatment must be administered at a certified facility that complies with the FDA’s Risk Evaluation and Mitigation Strategy (REMS) program.
- Typically requires documentation of previous treatment failures with traditional antidepressants.
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How Can I Find Out If My Insurance Plan Covers Spravato® Treatment?
Taking specific steps can help you determine if your insurance plan covers Spravato® treatment. Please follow these steps:
Call the customer service number on your insurance card and ask specifically about:
- Coverage for Spravato® (esketamine nasal spray)
- Prior authorization requirements
- Your specific copay or coinsurance amounts
- Which healthcare facilities in your network are certified to administer Spravato
- Any step therapy requirements (other treatments you must try first)
Review your insurance plan’s list of covered medications, which is typically available on your insurer’s website. Look for:
- Esketamine or Spravato® specifically listed
- The tier level (which affects your cost)
- Any coverage restrictions or requirements
Check your insurance company’s website for:
- Coverage policy documents for mental health medications
- Provider directories for certified Spravato treatment centers
- Online prior authorization forms or portals
Once you receive coverage information, request written confirmation of:
- Coverage details and limitations
- Your expected out-of-pocket costs
- Prior authorization approval
- Coverage duration and any renewal requirements
Coverage for Ketamine therapy near Oceanside, CA, can vary significantly even within the same insurance company based on your specific plan type, so always verify using your exact plan details rather than general company policies.
Can I Get Help From My Treatment Center to Verify Insurance Coverage for Spravato®?
The treatment center’s staff can be invaluable allies in verifying and securing insurance coverage for Spravato® treatment. Most certified Spravato treatment facilities have dedicated insurance coordinators or billing specialists who are experienced in navigating the complex approval process for this specialized medication.
When you contact or visit a treatment center, ask to speak with their insurance verification team, who can run a real-time benefits check using your insurance information to determine your exact coverage details, including copayments, deductibles, and any prior authorization requirements. These professionals understand the specific coding and documentation requirements that insurance companies look for when approving Spravato coverage and can often provide more detailed information than you might receive from calling your insurance company directly.
Treatment centers can also actively assist with the prior authorization process, which is typically required for Spravato coverage. Their clinical staff can work with your prescribing physician to compile the necessary medical documentation, including your treatment history, previous medication trials, and clinical assessments that demonstrate medical necessity for Spravato therapy.
Many centers will submit prior authorization requests on your behalf and follow up with insurance companies to expedite the approval process. Additionally, if your initial coverage request is denied, treatment center staff can help you understand the reason for the denial and assist with the appeals process. They may also have information about manufacturer assistance programs, sliding scale fees, or other financial resources that can help reduce your out-of-pocket costs while you work through insurance coverage issues.
Is Spravato® Covered by Insurance? Key Takeaways
- Most major insurance plans, including Medicare Part B, Medicaid, Blue Cross Blue Shield, Aetna, Cigna, UnitedHealthcare, and Tricare, do cover Spravato treatment.
- All insurance plans require prior authorization before approving coverage for Spravato.
- Insurance coverage is only available when Spravato is administered at healthcare facilities certified under the FDA’s REMS program.
- Certified Spravato treatment centers have specialized insurance coordinators who can verify your coverage, submit prior authorization requests, handle appeals if denied, and connect you with financial assistance programs.
- To confirm coverage, please contact your insurance provider directly, review your plan’s drug formulary, work with your healthcare provider’s billing team, and utilize any manufacturer support programs available.
To answer is Spravato covered by insurance, it’s important to understand the specifics of coverage options available to you. We encourage you to reach out to Moment of Clarity at 949-625-0564, where our knowledgeable staff can provide detailed information about what insurance plans typically cover regarding Spravato treatment.
