Does Medicare Cover Ketamine Nasal Spray: Coverage, Eligibility & Costs Explained

Understanding whether Medicare covers ketamine nasal spray, specifically esketamine (Spravato), is crucial for those with treatment-resistant depression. This medication offers hope when traditional antidepressants fail. Medicare Part B may cover esketamine administered in a medical setting, but it’s essential to confirm coverage details to manage treatment costs effectively.

Medicare Part B Coverage

Medicare Part B does cover ketamine nasal spray, specifically the FDA-approved esketamine (Spravato) for treatment-resistant depression. Coverage requires the spray to be administered in a medical facility by a healthcare professional. Medicare Part B typically covers 80% of the Medicare-approved amount, with the patient responsible for the remaining 20% and any applicable deductibles.

Medicare Part D Coverage

Medicare Part D helps cover the cost of prescription drugs, including ketamine nasal spray (specifically the FDA-approved esketamine, known as Spravato) for treatment-resistant depression. Here’s how it works:

1. Prescription Requirement: The nasal spray must be prescribed by a healthcare professional for an FDA-approved use.
2. Plan Coverage: Ensure your Medicare Part D plan includes esketamine in its formulary (the list of covered drugs).
3. Prior Authorization: You may need prior authorization, meaning your doctor must confirm that the treatment is medically necessary.
4. Administration: Esketamine must be administered under medical supervision, typically in a certified treatment center.

Beneficiaries should check their specific plan details and consult with their healthcare provider to understand the coverage and any out-of-pocket costs involved.

Eligibility Criteria

To be eligible for Medicare coverage of ketamine nasal spray (Spravato), the following criteria must be met:

1. Diagnosis:

   • Major Depressive Disorder (MDD) with acute suicidal ideation or behavior.
   • Treatment-Resistant Depression (TRD), defined as not responding to at least two different antidepressant treatments.

2. Administration:

   • Must be administered in a certified medical facility under the supervision of a healthcare provider.

3. Medicare Part B:

   • Coverage is provided under Medicare Part B due to the requirement for administration in a medical setting.

Cost and Reimbursement

Costs:

• Spravato (esketamine): $600 to $1,500 per treatment without insurance.
• With insurance: $10 to $100+ per treatment.

Medicare Reimbursement:

• Medicare Part B: Covers 80% of the Medicare-approved amount for the drug and its administration during a doctor’s visit.
• Out-of-pocket expenses: Beneficiaries pay 20% of the Medicare-approved amount and the Part B deductible, which was $185 in 2019.

Medicare Coverage for Ketamine Nasal Spray (Esketamine, Spravato)

Medicare covers ketamine nasal spray (esketamine, Spravato) for treatment-resistant depression under certain conditions.

Eligibility Requirements

To be eligible, beneficiaries must have a diagnosis of:

• Major depressive disorder with acute suicidal ideation or behavior
• Treatment-resistant depression that has not responded to at least two different antidepressant treatments

Administration and Supervision

The medication must be administered in a certified medical facility under the supervision of a healthcare provider.

Coverage Details

Medicare Part B covers 80% of the Medicare-approved amount for the drug and its administration during a doctor’s visit, with beneficiaries responsible for the remaining 20% and any applicable deductibles.

Important Note

It is essential to consult with healthcare providers to understand coverage details and out-of-pocket costs involved.