Are you sure you’ve heard that ketamine is one of the latest therapies for treatment-resistant depression or perhaps you’ve heard that it’s an emerging field of medicine involving psychedelic medicine and horse tranquilizers? You’re really confused, I’m sure. You’re reading this probably because you’ve heard that ketamine is a highly effective treatment that reduces emergency room visits and hospitalizations and is covered by insurance. Of course, it’s just a short course of infusions, but the response rates are close to 80%, which is jaw-dropping. Right?
The question of insurance coverage for ketamine will include three distinct components. There may be some slight variations, but for the most part, the answer is no, although there are certain situations where the answer may be yes.
Most major insurance companies will not cover ketamine infusions, which are billing codes related to infusions, such as EKG for the injection code or similar. This is because ketamine is not FDA-approved for mental health conditions like PTSD, anxiety, or depression, despite some indications from other mental health insurance companies, such as Blue Cross Blue Shield of North Carolina and Blue Cross Blue Shield of Illinois, that clearly state on their website that ketamine infusions will not be covered under any circumstances. However, some clinics may try to “get away” with billing codes that are related to ketamine infusions, but insurance companies are unlikely to provide coverage.
Some insurance companies may not reimburse the appointment reimbursement for the patient, unless the company’s insurance closely examines the records request and opposes it as part of the infusion appointment management and evaluation. However, some insurance companies may only reimburse these appointments for infusion management and evaluation, and providers might give out superbills for these purposes.
Obtaining coverage for ketamine infusions in the past was a difficult process, despite the fact that our facilities have obtained authorization for this treatment from insurance companies. Another insurance plan, Blue Cross Blue Shield of Massachusetts (BCBS MA), has recently released a formal policy and process for obtaining coverage for ketamine. However, there are some surprising exceptions.
In the coming years, our aspiration is for an increased availability of such plans. Nevertheless, at present, this advantage is rather uncommon. Enthea enables us to acknowledge insurance coverage for ketamine infusions and ketamine assisted therapy. An additional encouraging opportunity that we are eagerly joining is through Enthea, a unique perk offered by specific employer-sponsored health plans.
Depending on the month, the additional cost for the compound pharmacy is usually around $90. The ketamine itself is not covered by insurance, but these treatments are done in the comfort of the patient’s home. Most patients in the Psychedelic Medicine track do two sessions of assisted ketamine psychotherapy per week, plus group integration sessions. The IOP is covered by insurance and is a unique feature of the Psychedelic Medicine track. It is often difficult to find regular assisted ketamine therapy alone, but usually not impossible.
In recent times, the coverage of maintenance TMS is rarely, if ever, included, which is remarkable considering that some insurance companies even provide coverage for maintenance Spravato, which has a life-changing impact on many patients. In fact, as of 2023, most major insurance companies actually cover Spravato. They modified their policies multiple times within the same year, but in 2021, a few companies had already started providing coverage for it. Insurance companies require a significant amount of time to implement changes, despite the fact that Spravato received FDA approval for the treatment of treatment-resistant depression in late 2019. Patients are only able to choose between 56mg or 84mg due to the design of the spray bottles, but the drawback of Spravato is its difficulty in personalizing the dosage. Most reputable studies indicate that they have similar effectiveness, but there are some slight distinctions between esketamine and ketamine, although Spravato is essentially ketamine. Occasionally no, but mostly yes.
The packaged visit for the medicine will reimburse the insurance company and then the provider simply needs to purchase the medicine and the office visit are packaged together, meaning that the provider uses a “packaged code.” Some insurance companies require that the actual office visit. Some insurance companies require the pharmacy to obtain authorization for the actual medicine, and they may have a completely separate deductible, copay, or coinsurance for the medicine than they do for the medicine itself, and the office monitoring component. Spravato is considered in two distinct parts: the medicine itself, and most subsequent dosages are 84mg. The initial dose is 56mg, and the treatment is only used in the office, for a minimum of two hours at a time, twice per week. Spravato is slightly different from traditional ketamine assisted therapy and ketamine infusions.
If you’re struggling to navigate the complex world of insurance with ketamine, please give us a call to determine if any of our available options are suitable for you. All our offices are certified by REMS and can offer Spravato. Additionally, our Los Angeles offices can accept Enthea for ketamine infusions. For individuals in California who choose to work with a therapist and participate in ketamine assisted therapy at home, our IOP is now licensed.