Is Esketamine Covered by Insurance? What You Really Need to Know

If you’ve been battling depression that just won't budge, you've probably heard of Spravato. It’s the brand name for esketamine, and it’s basically the only FDA-approved version of ketamine therapy that isn't considered "off-label" for mental health. But let’s be real. The first thing anyone asks isn't "how does it feel?" but rather, "is esketamine covered by insurance?"

Honestly, the answer is a messy "yes, but."

In 2026, most major health insurance plans—think Blue Cross Blue Shield, Aetna, Cigna, and UnitedHealthcare—do cover esketamine. But they don't exactly make it easy. They won't just take your word for it that you're depressed. They want proof.

The "Treatment-Resistant" Hurdle

Insurance companies aren't just handing out Spravato like candy. Because it’s expensive (we're talking $600 to $900 per dose before you even factor in the clinic's fees), they require you to meet very specific criteria.

First, you usually have to be diagnosed with Treatment-Resistant Depression (TRD).

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What does that actually mean in the eyes of an insurance adjuster? Usually, it means you’ve tried at least two different oral antidepressants from two different classes (like an SSRI and an SNRI) for at least six to eight weeks each, and neither of them worked. Some plans are even pickier, demanding you’ve tried "augmentation therapy"—which is just a fancy way of saying you took a second med alongside your antidepressant—or that you've done a course of talk therapy like CBT.

There’s a second pathway for coverage: Major Depressive Disorder (MDD) with acute suicidal ideation. If things are at a crisis point, the approval process can sometimes be faster, but it still requires a mountain of paperwork from your psychiatrist.

Does Medicare Cover It?

Yes. Medicare Part B covers esketamine because it’s a drug that must be administered by a doctor in a clinic. You can’t take this home.

Typically, Medicare covers 80% of the cost. If you have a Medigap (supplemental) plan, that might pick up the remaining 20%. If you don’t, that 20% can still be a hefty chunk of change, especially during the "induction phase" when you’re going to the clinic twice a week.

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The Secret Costs: Medication vs. Observation

Here is where people get tripped up. There are actually two separate costs when you get an esketamine treatment:

1. The cost of the nasal spray itself.
2. The observation fee (since you have to sit in the office for two hours while a professional monitors your blood pressure and makes sure you don't have a bad reaction).

Sometimes your insurance will cover the drug but stick you with a massive bill for the "monitoring" time. It’s kind of a loophole. Some clinics charge a "facility fee" or a "procedural fee" that can range from $150 to $400 per visit. You’ve gotta ask your clinic specifically: "What is my total out-of-pocket cost per session, including the drug and the sit-time?"

How to Lower the Price Tag

If your insurance says "no" or the copay is just too high, don't panic yet. There are a few ways to hack the system.

• Spravato withMe Savings Program: This is a lifesaver for people with commercial insurance (unfortunately, it doesn't work for Medicare/Medicaid). If you qualify, you might pay as little as $10 per treatment for the medication.
• Observation Rebates: There’s also a separate rebate program that helps cover that annoying two-hour monitoring fee.
• The "Buy and Bill" Method: Some clinics purchase the drug themselves and bill your insurance as a medical procedure. Others make you get it through a specialty pharmacy. The "Buy and Bill" way is often smoother for the patient, so it's worth asking which one your doctor uses.

The Prior Authorization Headache

Expect a delay. Even if you meet all the criteria, your doctor has to submit a Prior Authorization (PA). This isn't a quick check; it's a deep dive into your medical history. It can take anywhere from a few days to three weeks to get the green light.

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And remember, you have to get treated at a REMS-certified facility. If you go to a random doctor who isn't certified by the FDA to handle esketamine, insurance won't pay a dime.

Actionable Steps to Get Approved

Don't just walk into a clinic and hope for the best. Follow this checklist to make sure you aren't stuck with a $5,000 bill.

1. Gather your "failure" history. Write down every antidepressant you’ve taken in the last five years, how long you took it, and why you stopped (e.g., "didn't work" or "bad side effects").
2. Verify the REMS status. Use the Spravato website to find a certified center near you. Don't assume your local psychiatrist's office is set up for it.
3. Ask for a "Benefits Investigation." Most good clinics have a dedicated billing person who will call your insurance for you and get a breakdown of your exact deductible and copay.
4. Enroll in the savings program. Do this before your first appointment. It’s a simple online form, and it can save you thousands.

Getting esketamine covered by insurance is definitely a hoop-jumping exercise, but for most people with major medical plans, it’s achievable if you have the right documentation.