Spravato is the brand name for the esketamine based nasal spray. Esketamine is similar to ketamine, and Spravato was FDA-approved in 2019 for treatment-resistant major depression as well as suicidal ideation. Since Spravato has been FDA approved for over 5 years now, it’s common to wonder just how much the first legal psychedelic medicine costs.
Spravato Treatment 101
Spravato is an antidepressant like no other. Instead of an oral pill, or a daily procedure like TMS, Spravato is self-administered in a short treatment course inside of a REMS certified treatment center. After the acute course is finished, patients are stepped down to maintenance therapy at the minimum effective dosage. A typical series of treatments with Spravato consists of two sessions per week for the first month, followed by one session per week for the next two weeks, and then one session over the following two weeks for a total of at least 11 treatments over 2 months. However, if the maintenance dosing is fairly dynamic, and some patients find that they are more stable staying at once per week per a longer period of time. Regardless of if the patient is on their very first session or their 30th session, patients must stay in the office for a minimum of two hours for continued monitoring. This monitoring includes any psychiatric symptoms that may arise during treatment, as well as making sure one is medically cleared to leave the facility and go back home.
Spravato is administered in two dosages: 56mg or 84mg. Patients with treatment-resistant depression must start on 56mg, but patients with suicidal ideation must start with 84mg and stay there for the remainder of their treatment series. Patients with treatment-resistant depression typically—but not always—end up increasing to 84mg.
Calculating the cost of Spravato
Spravato can be paid for in two different ways: the doctor’s office can pay for the medication, which is often called Buy & Bill. The other way that Spravato can be purchased is via the specialty pharmacy pathway, where the pharmacy benefits take care of the medication itself and monitoring is billed separately. When the doctor pays for the medication, they have to order it through a specialty distributor who is also REMS certified.
The Price of Spravato Buy and Bill
The cost of the esketamine nasal spray alone is between $600 – $1,000. When the doctor purchases the nasal spray through Buy and Bill, they are to then bill a combined code to insurance for the medication and the monitoring together. This means that insurance ends up paying approximately $1,400 – $2,000 per Spravato appointment. However, the cost for a patient depends entirely on their insurance benefits. For example, it’s not uncommon for a patient to have a $20 copay while their insurance covers over $1,300 of the session. Medicare mandates that Spravato must be paid for via the Buy and Bill pathway, which means that patients with supplementary Medicare policies usually have zero out of pocket costs.
The Price of Spravato Monitoring
Insurance companies tend to be the deciding factor as to whether Spravato is billed via the specialty pharmacy pathway or the Buy and Bill pathway. If a patient has an insurance that mandates the specialty pharmacy pathway like Cigna, then the Spravato clinic must bill through that pathway. On the clinic side, these are billed like regular doctor’s appointments, and the copays are often the same as any other doctor appointment with a specialist. On the other hand, the pharmacy benefits on the insurance policy might have a separate cost-share for the medication itself. Usually when Spravato is approved by insurance, the pharmacy contacts the patient with the full cost information.
Will Insurance Approve Spravato?
As of 2024, here are the insurance requirements in order for Spravato to be approved:
Aetna will cover Spravato as long as one has tried at least two antidepressants in two different medication classes.
Anthem Blue Cross (Carelon) will cover Spravto as long as one has tried at least two antidepressants in their lifetime.
Blue Shield of California (Magellan) will cover Spravato as long as one has tried at least two antidepressants in two different medication classes.
Cigna will cover Spravato as long as one has tried at least two antidepressants in two different medication classes.
Medicare doesn’t have a coverage policy for Spravato yet, although it is covered. It is safe to assume that the clinical criteria will mirror those of most of the private insurance companies.
United Healthcare (Optum) will cover Spravato as long as one has tried at least three antidepressants in their lifetime, no matter the specific classes.
If you or your loved ones are looking into the cost of Spravato, contact the Bespoke Treatment team today. We are more than happy to check on your insurance benefits for you to help give you an idea for how much you may have to pay.
