Esketamine nasal spray (brand name Spravato) is covered by most major insurance plans, but almost always requires prior authorization before your insurer will pay. This means your doctor needs to submit documentation proving you meet specific criteria before treatment can begin. The approval process, out-of-pocket costs, and exact requirements vary significantly depending on whether you have commercial insurance, Medicare, or Medicaid.
What Insurance Companies Require for Approval
Esketamine is FDA-approved for two conditions: treatment-resistant depression in adults, and depressive symptoms in adults with major depressive disorder who have acute suicidal ideation or behavior. Insurance companies use these approved uses as the starting point for coverage decisions, but most add their own layers of requirements on top.
For treatment-resistant depression, insurers typically want proof that you’ve already tried and failed other treatments first. Blue Cross Blue Shield of Michigan, for example, requires documented failure of at least two different oral antidepressants combined with two different augmentation therapies (such as lithium or buspirone), each tried for at least six weeks. They also require that you’ve been in cognitive behavioral therapy or interpersonal psychotherapy weekly for at least eight weeks. Other commercial insurers follow similar patterns, though the specific number of failed medications and therapy requirements can differ.
For the suicidal ideation indication, insurers generally require that you’re also receiving standard-of-care treatment, including therapy and an oral antidepressant. Your prescriber will need to submit chart notes and clinical documentation supporting your diagnosis.
If you’re approved, coverage isn’t open-ended. Insurers require renewal authorization, typically every six months, with documented proof that your depression symptoms have actually improved since starting treatment.
How Medicare Handles Esketamine
Medicare has specific billing codes (G2082 and G2083) that bundle the drug cost and the required two-hour observation visit into a single charge. This means the medication and the in-office monitoring aren’t billed as two separate items. However, having a billing code doesn’t automatically guarantee coverage. Your regional Medicare contractor makes the final decision about whether esketamine is covered in your area, and prior authorization requirements still apply.
Because esketamine must be administered in a certified healthcare setting rather than picked up at a pharmacy, it falls into a different coverage category than typical prescription drugs. If you’re on Medicare, ask your provider’s billing office to verify coverage with your specific plan before starting treatment.
Medicaid Coverage Varies by State
State Medicaid programs set their own rules for esketamine coverage. New York Medicaid, for instance, began covering Spravato in August 2022 with prior authorization. Their requirements include a baseline depression score using a validated assessment tool, a trial of at least two oral antidepressants beforehand (for treatment-resistant depression), and reassessment every six months showing improvement on the same scoring tool used at baseline.
Other states have their own timelines and criteria. If you’re on Medicaid, your prescriber’s office can check your state’s preferred drug list or contact the state Medicaid pharmacy program directly to find out what’s required.
What You’ll Actually Pay Out of Pocket
Even with insurance approval, esketamine can carry significant cost-sharing because of its high list price and the mandatory in-office administration. Each treatment session involves the drug itself plus a two-hour monitored observation period in a certified clinic, and both components factor into what you owe.
The manufacturer offers a copay assistance program for patients with commercial or private insurance that brings the cost down to $10 per treatment for the medication, with a $0 rebate for the observation portion. This program has annual limits and quantity caps (up to three nasal spray devices per day or 23 devices in a 24-day period). It does not apply to patients on Medicare, Medicaid, or other government-funded insurance.
Without copay assistance, your share depends entirely on your plan’s cost-sharing structure. Some patients with high-deductible plans face substantial costs early in the year before their deductible is met. During the induction phase, when treatments happen twice a week, those costs can add up quickly.
How to Improve Your Chances of Approval
The most common reason for denial is incomplete documentation. Before your provider submits the prior authorization request, make sure your medical records clearly show the antidepressants you’ve tried, how long you were on each one, why they didn’t work, and any therapy you’ve participated in. If your insurer requires a specific number of failed augmentation therapies, those need to be documented too.
If you’re denied, you have the right to appeal. Ask your insurer for the specific reason for denial, since it often comes down to a missing piece of documentation rather than a blanket refusal. Your prescriber can submit additional records or a letter of medical necessity addressing the exact gap the insurer identified. Many patients who are initially denied get approved on appeal once the paperwork is complete.
Your prescriber’s office should also confirm that the clinic where you’ll receive treatment is enrolled in the FDA’s required safety program (called REMS), since insurers will not cover esketamine administered at a non-certified location.