Esketamine, a breakthrough treatment for treatment-resistant depression (TRD), has given hope to individuals who haven’t found relief with traditional antidepressants. Sold under the brand name Spravato, esketamine is an FDA-approved nasal spray derived from ketamine, a drug long used for anesthesia and, more recently, for mental health conditions. But with its high cost, many patients wonder: Does Medicare cover esketamine?
Medicare Coverage for Esketamine (Spravato)
The good news is that Medicare does cover esketamine (Spravato), but only under specific conditions. Here’s how coverage typically works:
Medicare Part B (Medical Insurance)
Medicare Part B may cover Spravato (esketamine) as an outpatient service when it is administered in a REMS certified healthcare facility. Since Spravato requires medical supervision due to possible side effects—such as dizziness, sedation, and increased blood pressure—it must be taken in a clinical setting under the supervision of a prescriber such as a medical doctor, physician assistant, or psychiatric mental health nurse practitioner.
Coverage under Part B usually means that Medicare will pay 80% of the approved cost, and the patient is responsible for the remaining 20%, unless they have supplemental insurance (Medigap) to help with out-of-pocket costs. Should the patient have supplemental insurance, 100% of the cost of the drug and clinical monitoring are usually covered.
Medicare Part C (Medicare Advantage)
Some Medicare Advantage plans, also called Medicare Part C, may cover Spravato. However, this process usually requires prior authorization before the service is rendered. This can be tricky–but not impossible–depending on the specific plan.
Medicare Part D (Prescription Drug Coverage)
Some Medicare Part D plans may cover Spravato, but coverage varies by plan. Unlike traditional antidepressants, which are often taken at home, Spravato must be administered in a medical setting, making its coverage more complex. If a Part D plan covers it, the costs may include co-pays, deductibles, or prior authorization requirements.
Eligibility for Esketamine Coverage Under Medicare
To qualify for Medicare coverage of Spravato, patients generally must:
- Have a diagnosis of Major Depressive Disorder (MDD) or treatment-resistant depression (TRD)
- Have tried and failed at least two traditional antidepressant medications
- Receive the treatment at a Medicare-contracted facility
- Receive the treatment at a REMS-certified facility
How Much Does Esketamine Cost with Medicare?
Medicare usually covers the full cost of Spravato, as long as the patient has a supplemental policy. If there is no supplemental policy, the patient may owe up to 20% of the session. A session cost includes the drug itself as well as the clinical monitoring. Esketamine can be expensive, with costs averaging $600 to $900 per dose and monitoring around $300-$400 per session. Medicare Advantage plans may fully cover Spravato, but typically come with a copay of $20-$50 per session (consisting of the drug and monitoring). A full induction phase (initial treatment period) typically requires twice-weekly treatments for the first month, meaning costs can quickly add up.
Final Thoughts
If you or a loved one are considering Spravato (esketamine) for treatment-resistant depression, Medicare may cover it, but eligibility requirements, coverage details, and costs depend on your specific Medicare plan. Contact us today and to understand your coverage options and explore financial assistance if needed.
