For most New York insurance plans the answer is two. Aetna, Cigna, Optum (UnitedHealthcare) and New York Medicaid each want at least two antidepressant trials that did not help, and the commercial plans want them from two different drug classes. Cigna and Optum also count a medication you could not tolerate. Aetna adds an augmentation trial on top. Medicare's New York policy is worded differently: one failed trial that used medications from at least two classes, plus a psychotherapy trial.
These numbers are insurance rules, not medical ones. The devices themselves are FDA-cleared for adults whose depression has not improved with antidepressant medication in the current episode. Criteria also change, so treat the figures below as a guide and confirm the current requirement with your own plan before you count on coverage.
The requirement, payer by payer
Each row names the policy and the version quoted, all read on October 7, 2026.
| Payer and policy | Failed trials needed (adults) | Different classes? | Minimum length of each trial | Other medication requirement |
|---|---|---|---|---|
| Medicare, New York: LCD L33398, revision effective August 9, 2026 | One trial in the current episode, or intolerance of two trials | Agents from at least two classes | "Adequate course"; no weeks stated | Psychotherapy trial also required |
| NYS Medicaid: Medicaid Update Volume 41, Number 7 (coverage from October 1, 2025) | Two | Two different antidepressants; no class rule stated | "Sufficient duration" | None stated |
| Aetna: CPB 0469, last reviewed July 17, 2026 | Two | Yes, at least two classes | 8 weeks each, at the maximally tolerated labeled dose | Plus 8 weeks of augmentation |
| Cigna / Evernorth: EN0383, effective March 15, 2026 | Two or more | Yes, two separate classes | 4 weeks at an adequate therapeutic dose | Psychotherapy trial also required |
| Optum / UnitedHealthcare: BH803TMS112025, interim review April 21, 2026 | Two regimen trials | Yes, at least two classes | Not stated as weeks | None; psychotherapy requirement removed in 2023 |
| Carelon request form (used for some EmblemHealth members; undated) | Two, or intolerance of four | Yes, two classes | At least 6 weeks each | None on the form |
Anthem (formerly Empire BlueCross BlueShield) reviews TMS under MCG guideline B-801-T, 28th edition, effective September 1, 2024. That guideline is licensed rather than posted publicly, so this guide does not quote its medication count. New York law entitles you to request a plan's mental health medical-necessity criteria, so ask Anthem for the text in writing.
For teenagers aged 15 to 17, Aetna, Cigna and Optum ask for two trials and state no class requirement; Aetna also asks for psychotherapy or augmentation. See TMS for teens and young adults for the rest of the adolescent picture.
If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room.
What "two different classes" means
Antidepressants are grouped by how they act. Common classes include SSRIs (such as sertraline, escitalopram and fluoxetine), SNRIs (such as venlafaxine and duloxetine), bupropion, mirtazapine, tricyclics and MAO inhibitors. Two SSRIs in a row are two trials but only one class. Under a policy that requires two classes, that history may fall one trial short, even if both drugs failed.
Medicaid is the exception here: its wording is two different antidepressants, with no class requirement stated. If you are unsure how your medications are classified, ask your psychiatrist to list the class next to each one in your records.
What makes a trial "adequate"
A trial counts only if the medication had a fair chance to work. Plans judge that on two things.
Dose
Aetna asks for the maximally tolerated labeled dose; Medicaid and Cigna use "therapeutic dose" language. A starting dose that was never raised may not count, unless side effects stopped the increase.
Duration
This is where plans differ most: Aetna wants at least 8 weeks per trial, the Carelon form 6 weeks, and Cigna at least 4 weeks. Medicare and Optum do not set a number of weeks.
Timing
Medicare, Aetna and Optum count trials in the current depressive episode. Aetna adds that the episode must have occurred within the past five years. Medications from a depression ten years ago may help your psychiatrist's thinking but may not count toward coverage.
When side effects stopped a medication
You do not have to keep taking a drug that made you ill to qualify. Medicare accepts intolerance of two trials from two classes with distinct side effects. Cigna counts "documented intolerance or medical contraindication" as a failed trial, and Optum's criterion covers lack of response and/or inability to tolerate. The Carelon form allows intolerance of four trials from two classes as an alternative.
The word that matters is "documented." A note saying a medication caused nausea, sexual side effects, insomnia or emotional blunting, and that it was stopped for that reason, is what a reviewer looks for. If side effects are the main reason you are considering TMS, read stopped antidepressants because of side effects? Where TMS fits.
Aetna's augmentation requirement
Aetna's CPB 0469 is the strictest of the policies quoted: adults also need an inadequate response to augmentation therapy used with a primary antidepressant for at least 8 weeks. Augmentation means adding a second medicine to boost an antidepressant, for example lithium, thyroid hormone or certain atypical antipsychotics. The practice's article on augmentation for treatment-resistant depression describes the common options. Whether augmentation is right for you is a clinical decision first; it should not be started only to satisfy an insurer.
Why insurers settled on two
The rule tracks the usual definition of treatment-resistant depression, explained in What is treatment-resistant depression? It also reflects how the odds change with each new medication. In the large STAR*D study, remission rates were 36.8% and 30.6% for the first two treatment steps, then 13.7% and 13.0% for the third and fourth. A 2023 reanalysis using the protocol's original measures reported lower cumulative remission, a finding the original investigators disputed.
Coverage rules have loosened over time. Medicare's New York policy once required four failed medications; a 2018 revision changed that to one. A NeuroStar clearance from December 2008 described patients who had not improved on one prior antidepressant, and by 2016 the label simply referred to prior antidepressant medication. Canada's CANMAT 2023 guideline places TMS after first-line medication and psychotherapy, but says it can be a first choice when medications are poorly tolerated or when TMS worked in a previous episode.
Common situations, and how policies read them
Real medication histories are rarely tidy. These are the patterns that come up most often, and how the written criteria apply to them. Your plan's reviewer makes the final call, so treat this as a way to prepare, not a prediction.
One medication worked for years, then stopped working
Medicare, Aetna and Optum count trials in the current episode. If the old medication was continued into this episode at a full dose without benefit, it may count as one trial. Ask your psychiatrist to note that clearly, with the dose and the dates of this episode.
A medication was stopped after a few weeks
If it was stopped because of side effects, document the side effects; several policies accept intolerance. If it was stopped because it "wasn't working yet," it may fall short of a plan's minimum duration, which ranges from 4 to 8 weeks among the commercial policies quoted here.
Your antidepressants came from a primary care doctor
The policies quoted describe the trials themselves, not who prescribed them. What matters is the record: drug, dose, dates and outcome. Aetna does require the diagnosis itself to be confirmed by a psychiatrist.
You are taking two medications together right now
A combination can count. Medicare's wording refers to "mono- or poly-drug therapy," and under Aetna an add-on medication may satisfy the augmentation requirement. List each medicine separately, with its own start date.
You stopped all medication some time ago
Earlier trials in the same episode can still count. Note, though, that Aetna limits qualifying trials to an episode within the past five years.
How to document your history
Reviewers decide on paper. A clear medication history is often the difference between a quick approval and weeks of requests for records.
- List every antidepressant and add-on medication from the current episode: name, highest dose, start and stop month, and the reason it stopped.
- Pull pharmacy records from your pharmacy or patient portal to confirm dates and doses.
- Ask past prescribers for notes that mention response or side effects.
- Add any psychotherapy, since Medicare and Cigna require it alongside the medication history.
- Bring it to your consultation. The clinic uses it for the prior authorization request.
If you have not reached the count yet
Talk with your psychiatrist about the next medication step on its own merits, and about whether TMS makes sense now. How to bring up TMS with your psychiatrist offers a way to start that conversation. Some people choose to pay for TMS themselves rather than wait; what TMS costs without insurance covers that route. The TMS service page has the practice's current TMS information, and the TMS patient guide covers every other stage. Whatever your history, confirm your plan's current criteria with the plan itself before you start, because these policies are revised regularly.
Sources
- New York State Medicaid Coverage of Therapeutic Transcranial Magnetic Stimulation (NYS Medicaid Update, Vol. 41 No. 7). New York State Department of Health, 2025. healthweb-back.health.ny.gov
- Transcranial Magnetic Stimulation and Cranial Electrical Stimulation (Clinical Policy Bulletin 0469). Aetna, 2026. aetna.com
- Transcranial Magnetic Stimulation (Coverage Policy EN0383). Evernorth Health Services (Cigna), 2026. a.static.cigna.com
- Behavioral Clinical Policy: Transcranial Magnetic Stimulation (BH803TMS112025). Optum Behavioral Health Solutions, 2026. providerexpress.com
- LCD L33398 Transcranial Magnetic Stimulation (version 40). Wellpoint Federal (formerly National Government Services), CMS Medicare Coverage Database, 2026. cms.gov
- 510(k) K160703, NeuroStar TMS Therapy System. U.S. Food and Drug Administration, 2016. accessdata.fda.gov
- Repetitive Transcranial Magnetic Stimulation Request Form (commercial contracts). Carelon Behavioral Health, n.d.. carelonbehavioralhealth.com
- MCG Care Guidelines 28th edition (Anthem New York provider news). Anthem Blue Cross and Blue Shield (New York), 2024. providernews.anthem.com
- New York Insurance Law Section 3221 (group mental health coverage). New York State Senate, 2026. nysenate.gov
- Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. American Journal of Psychiatry, 2006. pubmed.ncbi.nlm.nih.gov
- What are the treatment remission, response and extent of improvement rates after up to four trials of antidepressant therapies in real-world depressed patients? A reanalysis of the STAR*D study's patient-level data with fidelity to the original research protocol. BMJ Open, 2023. pubmed.ncbi.nlm.nih.gov
- 510(k) K083538, NeuroStar TMS Therapy System. U.S. Food and Drug Administration, 2008. accessdata.fda.gov
- Canadian Network for Mood and Anxiety Treatments (CANMAT) 2023 Update on Clinical Guidelines for Management of Major Depressive Disorder in Adults. Canadian Journal of Psychiatry, 2024. pmc.ncbi.nlm.nih.gov
FAQs
Do two SSRIs count as two failed medications for TMS coverage?
They count as two trials but one class. Plans that require two classes, such as Aetna, Cigna and Optum, may not accept that history. New York Medicaid's wording asks for two different antidepressants without a class rule.
Does a medication I stopped after two weeks because of side effects count?
Often yes, if the intolerance is documented. Medicare, Cigna and Optum accept intolerance, with conditions. A short trial stopped without a documented reason is less likely to count.
Do I need to have tried ketamine or Spravato before TMS?
None of the New York policies quoted here list esketamine or ketamine as a prerequisite for TMS. They focus on oral antidepressants, augmentation (Aetna) and, for some plans, psychotherapy.
Does my therapy count toward the requirement?
Not toward the medication count, but Medicare and Cigna require a psychotherapy trial in addition. Aetna does not require it for adults, and Optum removed its psychotherapy requirement in 2023.
Can TMS be used before trying any antidepressant?
Insurers generally will not cover it then, and the FDA clearances for depression describe adults who have not improved with antidepressant medication. CANMAT does allow TMS as a first choice in some cases, such as poor medication tolerance.
