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Ketamine Therapy

Is Ketamine Therapy Covered by Insurance?

8 min read

Searching for ways to alleviate the symptoms and recover from depression is a long journey. Though Ketamine is initially recognized for its FDA-approved role in anesthesia and pain management, it has since been used to serve as a potent treatment across diverse medical conditions. There are a lot of research studies confirming its effectiveness in rapidly alleviating symptoms that are associated with treatment-resistant depression, suicidal tendencies, PTSD, and chronic pain, even at lower doses than traditionally administered for anesthesia, providing sustained relief for numerous individuals.

However, the financial burden of ketamine infusions poses a considerable obstacle for many patients, especially given the lack of coverage from most insurance providers for these treatments. Although ketamine therapy is gaining recognition as a transformative option for individuals who are looking for innovative mental health treatments, especially those with severe cases such as treatment-resistant depression, the majority of insurance companies in the United States do not officially cover it. Despite these financial and insurance challenges, there is hope for those grappling with financial constraints, as there are still resources available to assist in managing the costs associated with ketamine therapy.

The History and the Use of Ketamine

Ketamine has become a popular alternative treatment for depression and other mental health conditions in recent years. While it’s a popular option for treating mental health issues today, that wasn’t always the case.

Ketamine was synthesized in 1962 by Chemistry professor Calvin L. Stevens and initially showed promise in animal testing. By 1964, it was also experimented on human prisoners, demonstrating faster action and reduced toxicity compared to PCP, thus becoming a preferred anesthetic. Following successful trials, the FDA approved ketamine for medical use in 1970, notably for battlefield surgery during the Vietnam War. Despite its efficacy, ketamine soon became illicitly abused, particularly on the West Coast in the early 1970s. Academic and psychiatric research on ketamine’s effects commenced throughout the decade. In the 1980s, ketamine’s popularity as a party drug surged across the US, leading to various forms entering the street drug market, including capsules, powders, tablets, and injectables. It found a niche in subcultures like rave culture and was often sold as “ecstasy.” By the mid-80s, ketamine’s illicit use dominated discourse, earning the street name “Special K,” particularly prevalent in Hong Kong, where it remains a challenge today. In response, the United States classified ketamine as a federally controlled substance in 1999 to curb its illicit use. 

Ketamine’s medical and illicit usage declined after its classification. However, in the 2000s, medical professionals began recognizing its potential to alleviate depression and suicidal thoughts rapidly. Studies conducted between 2000-2006 confirmed ketamine as a promising alternative treatment for depression, leading to off-label use by doctors and the proliferation of ketamine clinics.

Today, mental health professionals utilize ketamine to treat treatment-resistant depression and conditions like PTSD. The FDA has expedited the approval of two ketamine-based drugs for depression treatment, signaling a growing recognition of its therapeutic potential.

Ketamine’s FDA Approval and Approved Uses 

The FDA’s approval of esketamine, a nasal spray derived from ketamine, marked a significant milestone in the treatment of major depression. This groundbreaking decision, made on March 5, 2019, introduced the first new medication for major depression in decades. Esketamine’s approval was expedited by the FDA due to its potential to offer relief to patients with treatment-resistant depression, who had not responded to standard treatments. The nasal spray formulation of esketamine enables easier administration in outpatient settings under the supervision of a healthcare professional, making it more accessible to patients than traditional IV ketamine treatments. This development represents a significant advancement in depression treatment, offering new hope to individuals struggling with this debilitating condition. 

What is Ketamine Therapy? 

Ketamine therapy is a treatment that uses ketamine, which is primarily known as an anesthetic. It’s gaining recognition for rapidly alleviating symptoms of depression, anxiety, PTSD, and chronic pain. Ketamine works by targeting the brain’s glutamate system, specifically the NMDA receptors, which play a crucial role in mood regulation and neural plasticity. By modulating glutamate transmission, ketamine may help restore normal brain function and alleviate symptoms of depression and other mental health disorders. 

Ketamine therapy is typically administered under the supervision of a trained healthcare provider in a clinical setting. Depending on the individual’s condition and treatment plan, ketamine may be given intravenously (IV), intramuscularly (IM), or through a nasal spray.

Spravato Nasal Spray

Spravato, also known as esketamine, is an intranasal spray derived from ketamine and designed specifically to address treatment-resistant depression (TRD). Since receiving FDA approval in 2019, Spravato has gained widespread acceptance among major insurance providers, with many offering coverage for the full cost depending on the patient’s insurance plan and treatment history.

To be eligible for Spravato treatment, patients generally need to be diagnosed with treatment-resistant depression. This diagnosis typically follows inadequate relief from two or more antidepressants, prompting consideration of alternative treatments such as Spravato. 

Is Ketamine Therapy Covered by Insurance? 

Insurance coverage for ketamine therapy varies depending on the insurance provider, the specific treatment being sought, and the individual’s diagnosis. While some insurance companies may cover certain forms of ketamine therapy, such as Spravato nasal spray for treatment-resistant depression, coverage for other types of ketamine therapy, such as intravenous infusions for depression or chronic pain, may be limited or not covered at all.

Forms of Ketamine Covered by Insurance and its Treated Diagnosis

Insurance coverage for ketamine therapy varies depending on the insurance provider and the specific diagnosis being treated. Generally, insurance is more likely to cover FDA-approved forms of ketamine therapy for specific diagnoses, such as:

Spravato (Esketamine Nasal Spray)

Approved for treatment-resistant depression (TRD) in adults who have not responded to other antidepressant medications.

Ketamine Infusions 

Coverage may vary depending on the diagnosis being treated. Ketamine infusions are often used for conditions such as treatment-resistant depression, PTSD, chronic pain, and certain mood disorders.

How Would I Check with My Insurance Plan?

To verify if your insurance plan covers Ketamine or Spravato, you should take a proactive approach. Start by thoroughly reviewing your insurance policy documents, paying close attention to any sections related to mental health coverage, prescription medications, or specialty treatments. Look for any specific exclusions, limitations, or requirements that may apply to these treatments. Next, reach out to your insurance provider directly to inquire about coverage for Ketamine or Spravato. You can do this by calling the customer service number on your insurance card or visiting the insurer’s website to find contact information. When speaking with a representative, be sure to ask specific questions about coverage for these treatments and any associated costs. 

Provide any necessary information about your medical history and diagnosis to determine eligibility for coverage. Your healthcare provider may need to submit documentation or prior authorization requests to support your case for coverage. Additionally, inquire about any restrictions or limitations on coverage, such as requirements for using in-network providers or meeting certain criteria for approval.

Are You Considering Spravato Ketamine Therapy?

Are you considering starting Ketamine Therapy, specifically Spravato, for treatment-resistant depression? If so, it’s a good idea to look for insurance companies that cover this treatment if you don’t already have insurance. If you are currently uninsured, here are some insurance providers you might want to consider.

4 Health Insurance Companies that Cover the FDA-Approved Form of Ketamine – Spravato (Esketamine)

Blue Cross Blue Shield 

Blue Cross Blue Shield (BCBS) offers coverage for the FDA-approved form of ketamine, which includes treatments like Spravato (Esketamine) for conditions that meet their criteria. It’s essential for BCBS members to check their specific plan details as coverage can vary.

MassHealth

MassHealth covers the FDA-approved Spravato for eligible conditions, offering support for patients under this plan to access ketamine therapy. Patients should consult with their healthcare provider and MassHealth for specific coverage details.

Medicaid

Medicaid provides coverage for the FDA-approved Spravato, indicating support for certain ketamine therapies under specific conditions. Coverage details can vary, so Medicaid recipients should inquire about their eligibility and coverage specifics.

Medicare 

Medicare includes coverage for FDA-approved forms of ketamine, specifically Spravato, for patients with conditions that meet the approval criteria. Like with other insurance types, Medicare beneficiaries should verify the specifics of their coverage.

Insurance-covered Spravato® Ketamine Treatment in Westchester, NY

Understanding insurance coverage for ketamine therapy is crucial for patients considering this treatment option. By focusing on FDA-approved treatments like Spravato, patients can improve their chances of securing insurance support. As always, consulting directly with insurance providers and healthcare professionals is key to navigating the complexities of insurance coverage for ketamine therapy. Should you encounter challenges in navigating the complexities of insurance coverage for Spravato® ketamine therapy, we invite you to contact us. Our team is on hand to discuss the range of options we offer and to determine the best course of action for your needs. Reach out here or call us at 1877-88-MARPA.

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