If you’re reading this, you’ve probably heard that ketamine is one of the latest helpful therapies for treatment-resistant depression. Perhaps you’ve heard that it is the first iteration of the emerging field of psychedelic medicine, or perhaps you’ve heard that it’s a horse tranquilizer, and you’re really confused. I’m sure you’ve seen the jaw-dropping response rates of close to 80% with just a short course of infusions. Surely insurance will cover a treatment that is highly effective, that reduces hospitalizations and emergency room visits, and prevents suicide. Right?
Yes and no, but mostly no. But a little bit yes. The question of insurance covering ketamine will be covered in 3 different parts:
- Are ketamine infusions covered by insurance?
Most major insurance companies will not cover ketamine infusions. Some clinics may “get away” with billing codes that are sort of related to infusions (like the code for an injection, or the code for an EKG). However, they’re really not supposed to, because ketamine is not FDA approved for depression, anxiety, PTSD, or any other mental health indication. In fact, some insurance companies, such as Blue Cross Blue Shield of North Carolina released a statement which very plainly stated that ketamine infusions will not be covered by insurance under any circumstances. Other Blue Cross Blue Shield companies (such as Kansas) have released similar states, and Blue Cross Blue Shield of Illinois created a page on their website where they clearly stated that billing ketamine infusions to insurance is considered fraud.
Some providers might give out superbills for ketamine infusions, where the patient can submit them to insurance company and hope for some reimbursement. Some insurance companies do reimburse for these, but they usually only reimburse for the “evaluation and management” part of the infusion appointment, as opposed to the infusion itself. If the insurance company looks closely enough to request records, they probably would not actually reimburse the patient for that appointment.
However, there are some surprising exceptions when obtaining insurance coverage for ketamine. Another BCBS plan—Blue Cross Blue Shield of MA—has released a formal policy and authorization process for obtaining coverage for ketamine infusions. Our facilities have obtained this authorization in the past, although the process was a bit difficult (as is usually the case when insurance companies cover new treatments).
Another promising option that we are excited to participate in is through Enthea, a special benefit for certain employer-sponsored health plans. Through Enthea, we are able to accept insurance coverage for ketamine infusions and ketamine assisted therapy. However, as of now, that benefit is quite rare. We hope that more plans are able to offer it in the future.
- Is ketamine assisted therapy covered by insurance?
Not usually. It is often hard to find regular therapy covered by insurance, let alone ketamine assisted therapy. We are unique in that we have an Intensive Outpatient Program (IOP) that features a Psychedelic Medicine track. The IOP is covered by insurance, and most patients in the Psychedelic Medicine track do two ketamine assisted psychotherapy sessions per week, plus a group integration. These are done from the comfort of the patient’s home. The catch, of course, is that the ketamine itself is not covered by insurance. Depending on the compound pharmacy, that additional cost is usually around $90 for the first month of the IOP.
- Is Spravato esketamine nasal spray covered by insurance?
Mostly yes, but sometimes no. Spravato is almost ketamine, and there are some slight difference between esketamine and ketamine, but most high quality studies report them to have basically the same efficacy. The downside to Spravato is that it’s really difficult to personalize the dosage—patients can choose from 56mg or 84mg only, because that’s just how the spray bottles are designed. Spravato was FDA approved for treatment-resistant depression in late 2019, but insurance companies take quite a bit of time to make changes. In 2021, a few companies had started covered it, but they changed their policies a few times in the same year. As of now in 2023, most major insurance companies do actually cover Spravato. In fact, some insurance companies cover 100% of the cost, which is life-changing for a lot of patients. Some even cover maintenance Spravato, which is impressive, considering maintenance TMS is rarely—if ever—covered these days.
Spravato is a little different from traditional ketamine assisted therapy and ketamine infusions. Spravato is a treatment used only in the office, for a minimum of two hours at a time, twice per week. The first dose is 56mg, and most subsequent dosages are 84mg. Spravato is thought of in two distinct parts: the medication itself, and the office monitoring component. Some insurance companies make the pharmacy obtain authorization for the actual medication, and they may have a totally separate deductible, copay, or coinsurance for the medication than they do for the actual office visit. Some insurance companies request that the provider utilize a “bundled code,” meaning that the medication and office visit are bundled together, and the provider simply has to purchase the medication and then the insurance company will reimburse them for the bundled visit.
If you’re having a tough time navigating the insurance maze with ketamine, give us a call to see if any of our options are right for you. Our offices are all REMS certified and able to provide Spravato, and our offices in Los Angeles are able to accept Enthea for ketamine infusions. Finally, our IOP is licensed in California for those opting to work with a therapist and engage in ketamine assisted therapy at home.