Spravato tends to have a clearer path to coverage, often with prior approval and specific criteria, because it is FDA-approved for defined uses. Ketamine for depression is harder to get covered, because that use is off-label and at least some insurers consider it experimental. Your own plan's written policy decides, and no general article can promise coverage.
Part of our guide: A Patient’s Guide to Ketamine and Spravato
The details that matter most are your plan's medical necessity criteria, whether your clinician is in or out of network, and how the treatment is billed. It is worth checking all three before you start.
If you are thinking about suicide or are in danger, call or text 988 (988 Suicide & Crisis Lifeline), call 911 or go to the nearest ER.
Why the two are treated differently
The FDA label is the main reason. The Spravato label lists two approved uses in adults: treatment-resistant depression, alone or with an oral antidepressant, and depressive symptoms in major depression with acute suicidal thoughts or behavior, with an oral antidepressant. By contrast, ketamine is not FDA-approved for any psychiatric disorder.
The FDA suggests asking your provider whether your health insurance will cover a drug used for an unapproved use. For patients, off-label status often means more questions about payment. Note that the approved Spravato uses are also specific. The Aetna policy described below considers all other uses of Spravato experimental, investigational or unproven.
What a real policy looks like: one example
Insurers publish coverage policies, and these can show what to expect. Aetna is used here only as an example. Other plans differ, and an employer plan can have its own rules. These policies are also updated regularly, so check the current version.
The Aetna policy on Spravato requires precertification in applicable plans. It says the medicine must be prescribed by or in consultation with a psychiatrist. For treatment-resistant depression, its criteria include:
- an inadequate response in the current episode to two antidepressants from at least two different classes, each used for at least 8 weeks within the past 5 years
- an inadequate response to an adequate trial of augmentation therapy or an evidence-based psychotherapy
The Aetna policy on ketamine lists depression among uses it considers experimental, investigational or unproven, for routes including intramuscular, intranasal, intravenous, oral and subcutaneous. It takes the same position on ketamine-assisted therapy for depression.
Notice that this policy's criteria go further than the common research definition described in this explainer on treatment-resistant depression. Records of past treatment can make a real difference, so gather what you can.
Records that can help with authorization
If a plan asks for proof of past treatment, your clinician will usually draw on records such as these. Gathering them early can save time:
- names, doses and dates of each antidepressant, with pharmacy printouts if you have them
- how long you took each one, and why it stopped
- any add-on medicines, and the type and length of past therapy
- depression rating scale scores from past visits, if any were recorded
- the plan's own prior authorization form and written criteria
- notes on any medical condition that shaped your earlier treatment choices
Records from other clinics can take time to arrive, so ask for them early. Do not change any treatment to meet a plan's criteria; that is a decision for you and your prescriber.
Costs to ask about, one by one
A treatment visit can involve several separate charges. Ask how each is handled:
- The medicine. Is it covered, and under the medical or pharmacy side of the plan?
- The session and monitoring time. Spravato requires at least 2 hours of monitoring at each session. Is that time billed, and how?
- The evaluation and follow-up visits. Are they covered differently from treatment visits?
- Any added psychotherapy. Is it billed on its own, and do visit limits apply?
- Repeat sessions. The label's schedule starts at twice weekly, so per-visit costs add up. Does approval expire, and what is needed to renew it?
Getting home is also part of planning. You should not drive until the next day, so include a ride in your plans.
Questions for your insurer
Call the number on your card, and write down the date, the representative's name and any reference number. Keep copies of everything you send or receive. You can ask:
- Is Spravato covered under this plan? Under which benefit?
- Is prior authorization needed, and what are the written criteria?
- Is ketamine for depression covered, by any route? Where is the written policy?
- Does this plan have out-of-network benefits for behavioral health? What are the deductible and coinsurance?
- Would an out-of-network claim for this treatment be treated differently?
- What are the steps to appeal a denial?
This guide to questions for your insurer goes further, and this article explains out-of-network benefits in New York.
If your claim is denied
A denial is not always the end. HealthCare.gov explains that you have the right to an internal appeal, and then to take your appeal to an independent third party. Ask for the reason in writing, and ask your clinician whether they can supply records that speak to the specific criteria.
Federal parity law can also matter when a plan has mental health benefits. The Mental Health Parity and Addiction Equity Act generally prevents plans that offer mental health benefits from imposing less favorable limits on those benefits than on medical and surgical benefits, and it covers limits like prior authorization. It does not require plans to offer these benefits in the first place. How it applies to one treatment is a specific question. This is general information and not legal advice, and rules vary by plan type and state.
If you pay on your own
If you do not have insurance or choose not to use it, the No Surprises Act rules generally mean providers must give you a good faith estimate of expected costs when you ask for one or schedule at least 3 business days in advance. This guide to good faith estimates explains how they work. For an extended series, ask whether the estimate covers the whole plan or a single visit.
Be cautious about choosing a product by price alone. Lower-cost compounded options raise the safety issues described in this article on the FDA's warnings.
How this works at Mind Body Seven
Mind Body Seven is an out-of-network practice. It does not accept Medicare or Medicaid, including managed Medicaid. For many clients with Cigna, Aetna or BCBS plans, the practice files out-of-network claims for them. For other carriers, such as UnitedHealthcare, superbills are available in the patient portal, and you can submit them yourself. This guide explains how superbills work. A Good Faith Estimate is available on request.
How Spravato specifically is billed here is a question for the intake team. Ask them before you begin, and ask whether your plan's authorization rules would apply to out-of-network care.
A note on urgency
Do not let a coverage question delay urgent care. If you are in crisis, use the options near the top of this page. Emergency care is not something to hold back on because of a benefits question.
Where to learn more
See the fees and insurance page for how the practice handles payment and claims. You can also read about Spravato and ketamine therapy at Mind Body Seven.
FAQs
Will a letter from a doctor get ketamine covered?
It may help in an appeal, but it cannot guarantee a result. Ask for the plan's exact policy first so that any letter can address its stated reasons.
Does Medicare cover Spravato?
Coverage depends on the type of Medicare plan and current rules, so check with your plan directly. Mind Body Seven does not accept Medicare or Medicaid.
Can an FSA or HSA be used for these treatments?
Rules depend on your account and how the expense is classified. Check with your account administrator or a tax professional, and keep itemized receipts.
Is it wise to change medication trials to qualify for coverage?
No. Never start, stop or change a medicine for insurance reasons on your own. Talk with your prescriber about what is clinically appropriate and what your plan requires.
