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Yes, Insurance May Cover Ketamine. Here's Where To Start

November 18, 2022

Ketamine-based therapies have proven to be a game-changing solution for many individuals struggling with mental health conditions, providing rapid relief after several other options have failed.

 

With any mental health intervention, it’s important for patients to determine whether it’s covered by insurance. This is especially so when it comes to ketamine and its newer cousin, SpravatoOut of pocket, Ketamine treatments can be expensive. For example, a round of six ketamine infusions can cost several thousand dollars at local clinics here in Austin, Texas, and online providers costs are similar with just a few months of treatment quickly adding up to thousands of dollars. Additionally, the effects of ketamine may not be robust or long-lasting when not supplemented with therapy or maintenance infusions. Studies have found the antidepressant effects of a single ketamine infusion last between four to seven days, while repeated infusions can extend this to several weeks.

 

Though through concurrent therapy, a much more sustained effect can be achieved, this is not widely offered – which is something we remedy with our team approach.

 

The truth is information about ketamine and insurance can be very confusing. For example, we looked at clinics in our nearby area of Austin. One clinic claims that ketamine is generally not covered by insurance, and many mention they do not accept insurance. As a result, while insurance can cover ketamine, those interested in receiving treatment will need to take special precautions to ensure they get the financial support they are entitled to through their plan.

 

Our team at Heading has worked hard to ensure we can provide coverage for the majority of our patients. 

How to Assess Whether Your Treatment Will Be Covered

While you won’t know for certain if any treatment will be covered before your insurance company receives a claim, you can gather strong evidence with the following steps.

#1 Ask Your Insurance Company if They Cover Ketamine-Based Treatments

Insurance coverage is determined on a case-by-case basis. Some companies don’t cover it at all. Before pursuing treatment or completing any other steps for assessing the likelihood that your treatment would be covered, call your insurance company and ask them if your policy covers ketamine for mental health conditions under any circumstances.

 

If the treatment is covered in specific scenarios, ask your insurance provider for specifics. For example, most insurance companies that cover ketamine require evidence of previous trials with other antidepressants (more on this below).

#2 Review Your Treatment History

Knowing your insurance company covers ketamine is a step in the right direction, but you’ll also need to know if they’ll cover your particular case.

 

Insurance companies generally want evidence that the treatment is 1) necessary and 2) likely to be effective enough to justify the cost of covering it. Demonstrating this often involves providing medical documentation proving you have tried several other interventions with unsatisfactory results. For example, when deciding whether to provide coverage for Spravato for a case of treatment-resistant depression (TRD), insurance companies most often want to know that you’ve tried two to three oral antidepressants (e.g., Prozac, Zoloft, Lexapro, etc.) and have not experienced a significant improvement.

 

The good news is that providing this information is simple if you know your history.

 

Your treatment history will be part of your evaluation with the prescribing physician at the clinic where you’ll be receiving your ketamine-based therapy. From there, they relay your treatment history and their recommendation to the insurance company, who will make a final determination.

#3 Check if Your Clinic Works with Insurance Companies

Despite the high cost and the need for repeat sessions of ketamine-based treatments, most clinics cannot secure coverage for their patients. Before settling on a treatment center, be sure to check if they work with insurance and ask how often they are able to secure coverage for patients. If you are considering at-home providers, do your research on insurance coverage and reach out to the company regarding finances prior to starting treatment.

#4 Determine Whether You’ll be Receiving Ketamine or Spravato (Esketamine)

If you’re looking around for ketamine-based treatments for your mental health condition, you’ve probably heard about ketamine and Spravato. Ketamine is a dissociative anesthetic whose antidepressant properties were first confirmed in 2000. Esketamine is structurally and therapeutically similar and is the active ingredient in Spravato.

 

Source: NeuroMend

Despite their commonalities, they are often treated very differently by insurance companies. Spravato is far more likely to be covered. The main reason is that Spravato is approved by the U.S. Food and Drug Administration (FDA) to treat TRD and major depressive disorder (MDD) with suicidal ideation.

 

Ketamine is not approved for any psychiatric conditions. This means that when ketamine is prescribed to treat a mental illness, it’s considered an “off-label” use. As Simon Tankel, CEO of Heading Health, notes, while insurance companies often cover off-label prescriptions for oral antidepressants, they are much more reluctant to do so in the case of ketamine because it’s significantly more expensive.

What to Do if Ketamine is Not Covered

Even if your ketamine treatments aren’t covered, you can take steps to make covering the cost of treatment more manageable. 

#1 Check if Your Clinic Offers Payment Plans

Though most clinics can’t secure insurance coverage for ketamine for their patients, many offer zero-interest payment plans that allow them to pay off the treatment in low-cost installments.

#2 Try to Get Reimbursed

Insurance companies that won’t cover the cost upfront might be willing to reimburse you after you have paid out-of-pocket.

 

When submitting a claim for reimbursement, it can be helpful to send your insurance company what is known as a “superbill.” This document contains several important pieces of information, including all of the services you received, along with relevant clinical data regarding your medical history. These superbills act as a “proof of service” and will help your insurance company decide whether they can offer you a partial or full reimbursement.

#3 Consider the Benefits of Psychotherapy and Ketamine Concurrently

Though not insurance specific, per se, it is important to consider how to foster longer-lasting effects and faster healing. Not only does faster healing improve your quality of life, it impacts your financial health too. Studies suggest that when psychotherapy and medication protocols align, it fortifies the benefits of ketamine treatment.

 

While psychotherapy is important regardless of whether insurance is covering your treatment, it’s absolutely essential when you’re paying the full price. Consider providers that can offer both or seek out a therapist or counselor familiar with ketamine treatment to ensure more optimal outcomes for your health and your wallet.

Is Ketamine Covered at Heading?

Yes. At Heading, we are proud to say that we are able to provide insurance coverage for both Spravato and Ketamine for the majority of our patients. Our team has worked closely with a wide array of insurance companies to highlight the advantages of ketamine-based therapies and demonstrate why it’s in their interest to cover them. Click here for a complete list of participating providers.  

 

Talk with your doctor to determine whether one of these treatments is right for you, or you can schedule an appointment with one of our psychiatrists or therapists to advise you on potential treatments for depression, including ketamine, Spravato, and TMS. Call us at 805-204-2502 or request an appointment here.

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