Medicare Part B covers Spravato, but only under specific conditions

Yes, Medicare Part B covers Spravato (esketamine), a nasal spray medication for treatment-resistant depression. However, coverage is not automatic. Medicare will only pay for Spravato if your doctor prescribes it in a hospital outpatient setting or a Medicare-approved clinic, and only after you have tried at least two other antidepressants without adequate relief.

The medication itself is expensive — the cost varies depending on the dose and how often you receive it — but Medicare Part B typically covers 80 percent of the approved amount after you meet your Part B deductible. You pay the remaining 20 percent as coinsurance, plus any facility fees charged by the clinic or hospital where you receive the injection.

Spravato is not covered if your doctor prescribes it in a private office setting or if you pick it up from a pharmacy to use at home. This restriction exists because the medication requires medical supervision during and after administration — patients must be monitored for at least two hours after each dose.

Key Takeaways

  • Medicare Part B covers Spravato only when administered in a hospital outpatient department or approved clinic, not in a doctor's private office or at home.
  • You must have tried and failed at least two other antidepressants before Medicare will cover Spravato for treatment-resistant depression.
  • Medicare pays 80 percent of the approved amount after your Part B deductible; you pay 20 percent coinsurance plus any facility charges.
  • Each Spravato dose requires two hours of medical monitoring, which is why it cannot be dispensed through a regular pharmacy.

What "treatment-resistant depression" means for Medicare coverage

Medicare defines treatment-resistant depression as depression that has not improved after you have taken at least two different antidepressant medications at adequate doses for adequate periods of time. "Adequate" typically means at least four to six weeks at a therapeutic dose, though your doctor may document a longer trial if side effects prevented you from reaching full dose.

Your doctor will need to document this history in your medical record before requesting coverage. Medicare's contractor in your state will review the documentation to confirm you meet this requirement. If you have only tried one antidepressant, or if you stopped one due to side effects rather than lack of effectiveness, Medicare may deny the request initially — though your doctor can appeal with additional information.

The two prior medications do not have to be the same class of antidepressant. For example, you might have tried an SSRI (selective serotonin reuptake inhibitor) and an SNRI (serotonin-norepinephrine reuptake inhibitor). What matters is that you tried them, stuck with them long enough, and they did not work.

How the approval process works

Your doctor or the clinic where you will receive Spravato will submit a prior authorization request to Medicare before your first appointment. This request includes your medical history, documentation of the two prior antidepressant trials, and the reason your doctor believes Spravato is medically necessary.

Medicare's contractor typically responds within 72 hours, though some requests take longer if additional information is needed. If Medicare approves the request, you can schedule your first Spravato appointment. If Medicare denies it, your doctor can file an appeal with more detailed documentation — for example, specific dates you took each medication and how long you remained on it.

Do not wait for approval before scheduling your appointment. Once approval comes through, clinics often have a waiting list. Scheduling early means you can start treatment sooner after Medicare says yes.

What happens during a Spravato treatment session

Spravato is administered as a nasal spray in a medical setting. Your first dose is typically 28 milligrams, and your doctor may increase it to 56 milligrams or 84 milligrams depending on how you respond and tolerate the medication. Most patients receive treatment twice a week for the first month, then once a week for the next four weeks, then once every two weeks or once a month for maintenance.

The entire visit lasts about three hours: 15 minutes for the nasal spray administration, two hours of monitoring in the clinic, and time for check-in and paperwork. During the monitoring period, a nurse watches for side effects such as dizziness, dissociation, or changes in blood pressure. You cannot drive yourself home after treatment, so you will need to arrange transportation.

Medicare Part B covers the medication and the professional services (the doctor's time and the nurse's monitoring). The facility where you receive treatment may charge a separate facility fee, which is also covered under Part B but counts toward your coinsurance.

Your out-of-pocket costs

Your costs depend on whether you have met your Part B deductible for the year. Once you meet the deductible, you pay 20 percent coinsurance on the approved amount for the medication and the clinic visit. The approved amount varies by region and by the dose you receive.

If you have a Medigap policy (supplemental insurance), it may cover some or all of your 20 percent coinsurance, depending on which Medigap plan you have. If you have a Medicare Advantage plan instead of Original Medicare, your costs may be different — check your plan's formulary and prior authorization requirements.

Some clinics offer financial information programs or payment plans if your coinsurance is high. Ask the clinic's billing department about these options before your first appointment.

What to do if Medicare denies coverage

If Medicare denies your prior authorization request, you have the right to appeal. Your doctor can submit additional documentation, such as specific dates and dosages of the antidepressants you tried, notes from your psychiatrist explaining why you are a good candidate for Spravato, or records from hospitalizations related to your depression.

The appeal process has multiple levels. A first-level appeal (called a redetermination) is reviewed by a different Medicare contractor reviewer and typically takes 60 days. If that is denied, you can request a second-level appeal (reconsideration) through an independent review entity, which also takes about 60 days.

Your doctor's office usually handles the appeal paperwork, but you can also submit information yourself. If you believe Medicare made an error — for example, if you actually did try two antidepressants but the documentation was unclear — include a clear, dated summary of your treatment history.

Spravato versus other depression treatments covered by Medicare

Spravato is one option for treatment-resistant depression, but it is not the only one. Electroconvulsive therapy (ECT) is also covered by Medicare for severe, treatment-resistant depression and may work faster than Spravato. Transcranial magnetic stimulation (TMS) is another option, though Medicare coverage for TMS varies by contractor and by the specific type of TMS.

Traditional antidepressants remain the first-line treatment and are covered by Medicare Part D (prescription drug coverage) if you have it. Psychotherapy is covered under Part B when provided by a licensed mental health professional. Your doctor can discuss which option makes the most sense for your situation, your timeline, and your preferences.

Some people use Spravato alongside an oral antidepressant rather than as a replacement. Medicare will cover both if your doctor prescribes them together for treatment-resistant depression.

Frequently Asked Questions

Can I get Spravato at my doctor's office instead of a hospital clinic?

No. Medicare only covers Spravato when it is given in a hospital outpatient department or a Medicare-approved clinic. Your doctor's private office does not meet Medicare's requirement for the level of monitoring needed. If your doctor's office is part of a hospital system, ask whether they have an outpatient clinic where Spravato is administered.

What if I have tried only one antidepressant?

Medicare will likely deny coverage if you have tried only one. However, your doctor can appeal and explain the circumstances — for example, if you had a severe allergic reaction or if you were hospitalized due to your depression despite being on that medication. The appeal gives your doctor a chance to argue that a second trial was not medically appropriate.

Does Medicare Part D cover Spravato if I pick it up from a pharmacy?

No. Spravato is not covered by Part D under any circumstances. It is only covered by Part B when administered in a medical setting. If a pharmacy dispenses it, Medicare will not pay, and you would be responsible for the full cost.

How long does it take to see results from Spravato?

Some people notice improvement within days or weeks, while others take several weeks. Your doctor will monitor your response and adjust the dose or frequency as needed. If Spravato is not helping after two to three months of treatment, your doctor may recommend stopping it and trying a different approach.

Will my Medigap plan cover the coinsurance?

Most Medigap plans cover at least some of your Part B coinsurance, but the amount varies by plan. Check your Medigap policy documents or call your insurance company to find out what percentage they cover for outpatient mental health services.