Ketamine, an FDA-approved pain reliever and anesthetic, is being recognized for its various therapeutic properties. According to decades of research, tiny dosages of ketamine can instantly aid with diseases such as depression, PTSD, and chronic pain, offering long-term relief. However, the cost of therapies might be a barrier for many. Unfortunately, most insurance plans do not pay ketamine for these use. Fortunately, there are solutions to assist manage spending.
This post is a helpful resource for anyone wanting to obtain insurance coverage or financial assistance for ketamine treatments.
- Understanding If Your Insurance Will Pay for Ketamine Therapy
- What About Coverage for Ketamine Infusions and Non-Oral Options?
- Understanding Spravato Insurance Coverage
- Actionable Ways to Check for Ketamine Therapy Insurance Coverage
- Other Ways to Reduce the Cost Burden of Ketamine Treatments
- Can Avesta Take Insurance Coverage for Ketamine Infusions?
- Frequently Asked Questions About Ketamine Insurance Coverage
- Hope for Expanded Coverage in the Future
Understanding If Your Insurance Will Pay for Ketamine Therapy
The first question many people ask is if their insurance will cover ketamine treatment. Unfortunately, the solution is not clear. Ketamine is commonly used “off-label” for mental health, which means it is not an FDA-approved treatment for disorders such as depression. As a result, coverage varies according to each insurer’s policy.
Some insurance, such as Aetna and Cigna, cover ketamine for mental health provided specific conditions are satisfied. However, many others consider it experimental and do not cover it. Self-funded employer health plans are likewise allowed to make their own coverage determinations. The best approach to determine whether you have coverage is to call your provider.
What About Coverage for Ketamine Infusions and Non-Oral Options?
In 2019, the new ketamine-based nasal spray called Spravato was FDA approved for depression. This has led some insurers to cover Spravato. However, coverage is still limited, often requiring pre-authorization or applying only after multiple failed antidepressant trials.
The most frequent ketamine therapies for mental health, intravenous infusions and intramuscular injections, remain off-label. Some insurance policies cover infusions or injections if Spravato is not an option for a patient. However, many insurers continue to deny claims for ketamine in non-Spravato forms.
Understanding Spravato Insurance Coverage
As an FDA-approved esketamine nasal spray, Spravato has the most clearly defined insurance coverage of any ketamine-based therapy. The maker of Spravato, Janssen, offers a program called Janssen CarePath that helps patients navigate insurance approval and offers co-pay assistance.
However, Spravato coverage is not without caveats. Aetna and UnitedHealthcare recommend Spravato as a second-line treatment for depression when many other antidepressants have failed. Prior authorization is necessary, which limits access. Even with coverage, Spravato may still face significant out-of-pocket expenses for copays and provider fees.
Actionable Ways to Check for Ketamine Therapy Insurance Coverage
If you are interested in pursuing ketamine for mental health treatment, here are practical steps to take to understand and obtain your insurance coverage:
Contact Your Insurer Directly First
Speaking with an agent from your insurance provider is the best first step. Explain that you are interested in using ketamine therapy for a mental health condition and ask if they have policies in place regarding coverage. Take note if ketamine treatment requires pre-authorization.
Request Prior Authorization If Needed
Some insurers require prior authorization before approving ketamine treatment – meaning your provider must demonstrate medical necessity. Your provider’s office will request authorization, but you can initiate the process. Be prepared to provide clinical documentation supporting your need.
Find Out About Potential Out-of-Network Coverage
Even if there are no in-network ketamine providers, your insurer may still cover some of the cost of out-of-network treatment. To better understand potential out-of-pocket expenses, inquire with your insurer about reimbursement rates for out-of-network ketamine providers.
Offer to Provide Superbills if Requested
A superbill is an itemized receipt that providers can give to patients who pay out of pocket. If your insurer agrees to a partial reimbursement, offer to provide superbills for submitting claims. The reimbursement is not guaranteed, but superbills can help demonstrate details if necessary.
Other Ways to Reduce the Cost Burden of Ketamine Treatments
If your insurance denies coverage for ketamine, there are still options to reduce your out-of-pocket expenses:
Use HSA or FSA Funds
If you have a Health Savings Account (HSA) or Flexible Spending Account (FSA), you can use these pre-tax funds for ketamine treatment. Paying with an HSA or FSA debit card allows you to pay today but reimburse yourself from your tax-advantaged accounts.
Explore Monthly Payment Plans
Ask your provider if they offer monthly payment plans to break up ketamine costs over time. Making smaller payments over several months is often more feasible than paying the full amount for a set of treatments upfront.
Look Into Medical Financing Companies
Third-party medical financing companies like CareCredit allow you to pay for medical expenses like ketamine over 12, 18, or 24 months. This spreads payments out with either no interest or fixed lower interest rates.
Can Avesta Take Insurance Coverage for Ketamine Infusions?
Avesta, a national ketamine clinic, uses insurance coverage whenever possible to reduce patient costs. Avesta accepts insurance for Spravato treatments. The Avesta will provide superbills for IV and IM ketamine so that patients can submit them for reimbursement from insurers that allow out-of-network coverage.
Avesta also offers personalized payment plans. Avesta also provides 0% interest financing for 3, 6, or 12 months as part of a partnership with CareCredit. This clinic aims to make ketamine therapy more affordable by combining insurance, payment plans, and financing options.
Frequently Asked Questions About Ketamine Insurance Coverage
As you navigate insurance options for ketamine, here are answers to some questions that often arise:
Is Ketamine Therapy Covered by Insurance with Medicaid?
Each state administers Medicaid differently, so ketamine coverage varies. Off-label ketamine is covered by Medicaid in some states, including California and Texas. Other states continue to classify it as experimental, denying coverage. The best way to find out is to contact your state Medicaid office.
Does Medicare Insurance Cover Ketamine Infusions?
No, standard Medicare insurance does not currently cover ketamine therapy for mental health conditions. Medicare considers ketamine experimental for conditions like depression. Unless ketamine is covered by a secondary insurer, Medicare enrollees must pay out-of-pocket.
Are Certain Medical Conditions More Likely to Have Ketamine Coverage?
Yes, insurers are more likely to cover ketamine when prescribed for certain FDA-approved medical indications like pain management. Conditions like complex regional pain syndrome (CRPS) and neuropathic pain often have defined ketamine coverage policies. Mental health uses are less likely to be covered.
What Does Ketamine Therapy Cost Without Insurance?
Out-of-pocket costs for ketamine vary across providers. But as a ballpark, a standard course of 6 IV ketamine infusions may range from $2,000-$6,000 without insurance. Spravato costs roughly $1000 or more per month. Explore payment plans to affordably manage uninsured expenses.
Hope for Expanded Coverage in the Future
While ketamine insurance coverage remains limited today, there are promising signs it could expand in the future. If additional ketamine therapies like intranasal esketamine gain FDA approval for mental health, more insurers are likely to develop coverage policies.
Advocacy and education also play a role. The more insurers see ketamine positively impact patients’ lives, the more they may be convinced to provide coverage. Patients should not be deterred from exploring this promising treatment option just because of insurance. There are paths to make care affordable in the meantime. The future is bright when it comes to access to innovative mental health treatments like ketamine.
