Is Spravato Covered by Insurance? Breakdown for those in New York

Spravato is a potentially life-changing treatment that can be financially accessible through insurance. Read below to learn more about insurance coverage for Spravato and the factors affecting its cost. 

What is Spravato?

Spravato is a nasal spray form of esketamine, one of the two chemical components that make up ketamine. In 2019, esketamine was approved by the U.S. Food and Drug Administration (FDA) for treatment-resistant depression (TRD). One year later, it was also approved for major depressive disorder with suicidal ideation (MDSI). Over 80,000 patients in the U.S. have since received Spravato through prescription. 

Whereas typical antidepressants primarily target serotonin, a chemical messenger, Spravato interacts with proteins called NMDA receptors. This leads to several downstream effects, including:

• Boosting Prefrontal Cortex Activity – Supports better emotional control and motivation, which are often underactive in people with depression.

• Strengthening Brain Connections – Enhances synaptic plasticity, improving the strength of nerve circuits involved in mood and emotional regulation.

• Improving Functional Connectivity – Helps different brain regions communicate and shift thought and behavior patterns.

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How Much Does Spravato Cost?

Without insurance, Spravato can be costly. Wholesale prices for each dose range from around $600 to $800, and the initial treatment phase involves eight doses followed by maintenance doses thereafter. With added clinic visit costs, the overall cost of Spravato treatment can be financially inaccessible for many. However, most insurance plans fortunately cover the drug. 

Is Spravato Covered by Insurance in New York?

Spravato is generally covered by most insurance providers in New York. This includes government programs like Medicare, as well as leading private insurance companies. 

At Aurora Wellness, we are in-network with several major insurance providers, making Spravato treatment more affordable for our patients. Being in-network means we have pre-negotiated rates with these insurers, reducing your out-of-pocket costs.

We are in-network with:

• Aetna

• Cigna

• Tricare

• UnitedHealthcare (UHC/Optum)

• Blue Cross Blue Shield (BCBS)

• Humana

• Capital District Physicians' Health Plan (CDPHP)

• MVP Health Care

• Carleon

• Medicare

However, not all companies cover treatment, and it is essential to confirm with your provider whether Spravato is covered before undergoing treatment. Coverage also depends on whether you meet the clinical criteria and if you have the necessary prior authorization. To be eligible, you must:

• Be 18 or older

• Have no serious medical conditions that could make Spravato unsafe

• Have a qualifying diagnosis, such as TRD and MDSI

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Is Spravato Covered by Medicaid?

In New York State, Medicaid covers Spravato under certain conditions. To get coverage, patients must meet the medical criteria, and a doctor needs to fill out a form called the Spravato Clinical Criteria Worksheet. This form helps Medicaid decide if the treatment is necessary. Since rules can change, it’s always a good idea for patients to check with their Medicaid provider to confirm coverage.

For Medicare, Spravato can be covered under Medicare Part B, which helps pay for outpatient treatments given by a healthcare provider. Medicare generally covers 80% of the cost, and the patient is responsible for the remaining 20%. However, not all Medicare plans cover Spravato, so it’s important to get in touch with your provider and find out your costs. 

Factors Affecting Spravato Costs

Insurance Plan Type 

Coverage depends on whether you have private insurance, Medicare, or Medicaid. Some plans cover Spravato fully, while others require patients to pay a portion of the cost. 

Deductibles & Co-Pays 

A deductible is the amount you must pay out-of-pocket before insurance starts covering costs. Even after meeting your deductible, you may still have a co-pay (a fixed fee per visit) or co-insurance (a percentage of the treatment cost you must pay). These expenses can add up, especially in the first month of treatment when Spravato is administered twice weekly.

Prior Authorization 

 Most insurance providers require prior authorization, meaning your doctor must submit paperwork proving that Spravato is medically necessary. This step can take time and have costs. 

Facility & Monitoring Fees

Since Spravato must be taken under medical supervision, you’re not just paying for the medication but also for the clinic’s services, including the time you spend under observation after each dose. 

Dosage & Treatment Length 

There is a standard protocol for the initial treatment phase of Spravato. However, the maintenance phase can vary depending on a patient's progress. It lasts as long as the patient needs it, and some patients may require biweekly rather than weekly doses. 

Spravato Coverage at AuroraWellness

Navigating insurance for Spravato can be tricky, but at Aurora Wellness, we’re here to help. Here are three steps you can take to understand and get the most out of your insurance. We can help you submit paperwork, advocate for approval, and guide you through different financial assistance options if your insurance doesn’t cover Spravato or additional costs are too high. 

If you want to learn more about our services, you can get in touch by email or giving us a call.

Key Takeaways:

• Spravato is a nasal spray treatment for treatment-resistant depression and major depressive disorder with suicidal ideation.

• Costs for Spravato can range from $600 to $800 per dose without insurance.

• Insurance coverage for Spravato can depend on the type of plan, prior authorization, and whether the provider is in-network.

• At Aurora Wellness, we offer assistance with insurance verification and access to financial assistance programs.