Insurance Coverage for Ketamine Therapy

Esketamine (Spravato)

• FDA-approved; usually requires prior authorization.
• Coverage typically requires documented failure of two or more antidepressants.
• Must be administered at a certified REMS-program site.
• Out-of-pocket cost varies by plan and benefit design.

Off-label racemic ketamine (IV, IM, intranasal compound, sublingual)

• Generally not covered by insurance.
• Some plans reimburse the office visit, monitoring, or anesthesia line items.
• Out-of-network reimbursement is occasionally possible with a superbill.
• FSA/HSA funds can sometimes be used; verify with your plan administrator.

Adjunct therapy and integration

• Standard psychotherapy is often covered under mental health benefits.
• Specialized integration sessions billed as "psychotherapy" may be covered when delivered by a licensed clinician with appropriate CPT codes.
• Group integration programs are usually out-of-pocket.

Practical steps

• Call the number on the back of your insurance card; ask about benefits for "esketamine (Spravato)" and "ketamine infusion".
• Ask about prior authorization requirements and required documentation.
• Ask the clinic which CPT codes they bill and whether they provide a superbill.
• Get written estimates of patient responsibility before scheduling.
• If denied, ask about an appeal - documented medical necessity sometimes succeeds.