Navigating Spravato Insurance Coverage: A Florida Patient’s Guide

If your doctor has recommended Spravato for treatment-resistant depression, your first question is probably about cost. The good news: most major insurance plans cover Spravato when medical necessity criteria are met. The challenging news: navigating prior authorization, understanding what you’ll actually pay, and knowing which plans KCSF works with requires some homework.

This guide walks you through everything Florida patients need to know about Spravato insurance coverage, from which plans typically approve treatment to what your out-of-pocket costs might look like.

What Makes Spravato Different from Regular Ketamine

Spravato (esketamine) is FDA-approved specifically for treatment-resistant depression and major depressive disorder with acute suicidal ideation. This FDA approval is crucial, and it’s why most major insurers include Spravato as a covered benefit when you meet their medical necessity criteria.

The treatment must be administered in a certified Spravato clinic with medical supervision. You cannot take Spravato home. Each session involves nasal spray administration followed by a mandatory two-hour observation period. During this time, our team monitors for side effects while providing integration support to help you process the experience and maximize therapeutic benefits.

Which Insurance Plans Cover Spravato in Florida?

At the Ketamine Wellness Clinic of South Florida, we currently accept Aetna, UnitedHealthcare, and Cigna for Spravato treatment. Most major commercial insurance plans provide coverage when medical necessity is established:

Medicare Part B covers Spravato because it must be administered in a clinical setting. Medicare typically pays 80% of costs after you meet your annual deductible ($283 for 2026), leaving you responsible for 20% coinsurance per session.

Commercial Insurance (Aetna, Cigna, UnitedHealthcare, Blue Cross Blue Shield, Anthem) generally covers Spravato with prior authorization. Your out-of-pocket costs depend on your specific plan: some charge copays, others charge coinsurance.

Medicaid coverage varies by state. Florida Medicaid programs generally cover Spravato, though specific formulary placement and criteria differ from commercial plans.

Tricare provides coverage for eligible beneficiaries who meet clinical criteria.

The key across all plans: prior authorization is required. Your clinic must submit documentation proving Spravato is medically necessary before treatment can begin.

Medical Necessity Criteria: What Insurance Requires

Insurance companies don’t approve Spravato for everyone with depression. You must meet specific clinical criteria, which typically include:

Diagnosis Requirements:

• Treatment-resistant major depressive disorder (failed at least two different antidepressants from different drug classes at adequate doses and duration)
• OR major depressive disorder with acute suicidal ideation or behavior

Treatment History Documentation:

• Evidence you’ve tried at least two antidepressants (sometimes more, depending on the insurer)
• Documentation of adequate trial duration (usually 6-8 weeks per medication at therapeutic doses)
• Some plans require you’ve also tried therapy or augmentation strategies

Ongoing Requirements:

• Must continue taking an oral antidepressant alongside Spravato
• Treatment administered only in certified facilities
• Regular monitoring and documentation of response

Exclusions: Most plans exclude coverage if you have moderate or severe substance use disorder that isn’t currently being treated. Some plans have additional restrictions around certain medical or psychiatric conditions.

The Prior Authorization Process

Prior authorization feels bureaucratic, but understanding the process helps set realistic timeline expectations:

1. Initial Evaluation: Your provider assesses whether Spravato is clinically appropriate and gathers documentation of previous treatment failures.
   
2. Submission: The clinic submits a prior authorization request to your insurance, including:
   
   • Diagnosis codes
   • Treatment history showing failed antidepressant trials
   • Current symptom severity scores (often PHQ-9 or similar)
   • Clinical notes supporting medical necessity
3. Insurance Review: The insurer reviews the submission, which typically takes 72 hours to 2 weeks. They may request additional documentation.
   
4. Approval or Denial: If approved, you’ll receive authorization for a specific number of sessions (often the initial 8-week induction phase). If denied, you can appeal.
   
5. Ongoing Reauthorization: Most plans require periodic reauthorization (every 3-6 months) with documentation that treatment is working.
   

At KCSF, our team handles the prior authorization process. We submit all required documentation and follow up with your insurer to expedite approval.

What Will You Actually Pay?

Even with insurance coverage, you’ll have out-of-pocket costs. Here’s what to expect:

Medicare Patients:

• Pay 20% coinsurance after meeting the $283 deductible
• Each session costs $700-$1,200 total (your 20% = $140-$240 per session)
• Initial phase (twice weekly for 4 weeks) = 8 sessions
• Medigap plans (Plans G or N) may cover the 20% coinsurance

Commercial Insurance Patients:

• Costs vary widely by plan
• Some plans charge flat copays ($50-$150 per session)
• Others charge coinsurance (10-30% of total cost)
• High-deductible plans require meeting your deductible first
• Call your insurer using the member services number on your card to ask specifically about Spravato coverage and your cost-sharing

Example Cost Scenarios:

Scenario 1: Medicare + Medigap Plan G

• Medicare pays 80%, Medigap pays your 20%
• Your cost: $0-minimal per session after deductible

Scenario 2: Commercial plan with $2,000 deductible (not yet met)

• You pay full cost until deductible met: ~$700-$1,200 per session
• After deductible: copay or coinsurance kicks in

Scenario 3: Commercial plan, deductible met, 20% coinsurance

• You pay ~$140-$240 per session

Treatment Phases and Total Costs

Understanding the treatment schedule helps you budget:

Induction Phase (Weeks 1-4):

• Two sessions per week = 8 total sessions
• Typical dosing: 56mg or 84mg per session

Maintenance Phase (Ongoing):

• Weekly or every-other-week sessions
• Frequency adjusted based on your response
• Some patients maintain on monthly sessions

Insurance typically covers both phases, but reauthorization may be required to continue into maintenance.

What If Insurance Denies Coverage?

Denials happen, but they’re not always final:

Common Denial Reasons:

• Insufficient documentation of failed antidepressant trials
• Treatment history doesn’t meet specific plan criteria
• Missing required psychiatric consultation
• Coding errors in the submission

Your Options:

1. Appeal: Your clinic can submit additional documentation addressing the denial reason. Many denials are overturned on appeal.
   
2. Peer-to-Peer Review: Your doctor speaks directly with the insurance company’s medical reviewer to explain why Spravato is medically necessary for your case.
   
3. Manufacturer Assistance: Janssen (Spravato’s manufacturer) offers support programs that may help with costs if insurance won’t cover treatment.
   

Questions to Ask Your Insurance Company

When you call your insurer, have your member ID ready and ask:

• “Does my plan cover Spravato (esketamine) for treatment-resistant depression?”
• “What are my cost-sharing responsibilities? (copay vs coinsurance vs deductible)”
• “How many antidepressant trials must I have documented?”
• “Is prior authorization required, and how long does it typically take?”
• “How many sessions are approved initially?”
• “What documentation is needed for reauthorization?”
• “Does treatment need to be at an in-network facility?”

KCSF’s Role in Your Insurance Journey

At Ketamine Wellness Clinic of South Florida, we handle insurance complexity so you can focus on getting well:

• Verification: We verify your Spravato coverage before you start treatment
• Prior Authorization: Our team submits and follows up on all authorization requests
• Documentation: We maintain detailed clinical records supporting medical necessity
• Appeals: If your initial request is denied, we work with you to appeal
• Transparent Billing: You’ll know your estimated costs before beginning treatment

We currently accept Aetna, UnitedHealthcare, and Cigna. If you have different coverage, contact us to discuss options, as insurance landscapes change, and we’re continually working to expand our accepted plans.

Understanding the Value Beyond Cost

While navigating insurance feels overwhelming, remember what you’re working toward. Treatment-resistant depression severely impacts quality of life, relationships, work performance, and physical health. Spravato offers rapid relief for many patients who’ve tried everything else.

The initial time investment in securing insurance approval often pays off in the form of manageable ongoing costs and access to a treatment that could genuinely change your life.

Your Next Steps

If you’re considering Spravato treatment:

1. Confirm Your Diagnosis: Ensure you meet criteria for treatment-resistant depression or MDD with suicidal ideation
2. Gather Treatment History: Document which antidepressants you’ve tried, at what doses, for how long
3. Contact KCSF: Schedule a consultation to discuss whether Spravato is clinically appropriate
4. Verify Coverage: We’ll check your insurance and begin the prior authorization process
5. Plan Financially: Once approved, you’ll know your per-session costs and can budget accordingly

Insurance shouldn’t be a barrier to accessing effective mental health treatment. While the process requires patience, most patients who meet clinical criteria successfully obtain coverage. Our team at KCSF navigates insurance complexities daily and can guide you through each step.

Questions about your specific coverage situation? Contact our Pompano Beach clinic and we’ll help you understand your insurance benefits and estimated costs for Spravato treatment.