Insurance and Esketamine Treatment and Ketamine Therapy

A psychiatrist who treats patients who have treatment-resistant depression has a new treatment option in their arsenal. Ketamine and esketamine treatment can help patients start seeing relief from depression symptoms in as little as 24 hours when used in combination with traditional antidepressants. However, it is important for patients to consider whether their insurance company covers the treatment before asking their mental health professional about it.

Ketamine treatments and insurance

Patients receive ketamine treatment via IV infusions from a psychiatrist and clinician. It is the most common type of ketamine therapy. While the FDA approved ketamine as an anesthetic long ago, it has not yet given approval for its use as a mental health treatment. For this reason, most patients will not be able to ask their insurance company to pay for IV ketamine treatments. However, patients who suffer from chronic neuropathic pain may be able to receive the treatment and have insurance cover the costs. This is common for those who have fibromyalgia or chronic migraines.

There is another type of ketamine treatment known as esketamine. It is most commonly called Spravato. The patient receives the medication via a nasal spray treatment once or twice per week. Because Spravato has FDA approval, insurance companies are more likely to cover its cost. However, esketamine is only available for patients who meet the criteria and receive a diagnosis of treatment-resistant depression. 

How to find out if your insurance covers ketamine treatment

There are several steps you can take to determine if your insurance provider will cover ketamine treatments.

Check with your provider

Call your insurance provider and ask if the company offers any coverage, whether in full or in part, for ketamine or esketamine treatments. Most of the time, providers that do offer coverage do so on a case-by-case basis. There is also the possibility that the provider will cover it if they can designate it as "a generic drug infusion." If your provider covers ketamine treatments, you will receive an explanation of benefits that details the costs and what the provider will cover. Keep in mind that you may need to meet your deductible first.

Ask about reimbursement for out-of-network care

Sometimes, an insurance provider will require you to pay out of pocket and then reimburse you down the road. Unless your policy expressly says that the provider will not cover out-of-network care, it will likely cover out-of-network care. Each insurance provider pays out these claims differently, but typically you will receive full or partial reimbursement a few weeks after your appointment. 

Provide a superbill if necessary

Some insurance providers will only cover out-of-network care for ketamine treatments if you provide them with a superbill first. A superbill is an itemized invoice of the ketamine or esketamine treatment you received. It includes information such as the clinician's name, the treatment you received, the date of the services, and your own personal information. This is known as proof of service. Typically, a provider will ask for one of these if they want more information about the claim that you submitted before they will pay out on it.