Is Spravato Covered by Medicaid

Spravato, also known as esketamine, is a medication used to treat depression. It is administered as a nasal spray and is typically used in conjunction with an oral antidepressant. Spravato is not covered by Medicaid in all states, and the coverage criteria vary from state to state. In some states, Spravato may be covered for people with treatment-resistant depression who have tried and failed at least two other antidepressants. In other states, Spravato may only be covered for people with severe depression who are at risk of suicide. If you are interested in using Spravato, you should talk to your doctor and your state Medicaid office to see if you are eligible for coverage.

How Medicaid Covers Spravato

Spravato (esketamine) is a nasal spray medication used to treat treatment-resistant depression (TRD). TRD is a form of depression that does not respond to traditional antidepressants. Spravato is FDA-approved for use in adults with TRD who have not responded to at least two other antidepressants.

Medicaid is a government health insurance program that provides coverage for low-income individuals and families. Medicaid programs in some states cover Spravato for TRD. Coverage varies from state to state, so it is important to check with your state Medicaid program to see if Spravato is covered.

Coverage Details

  • Who is eligible? Medicaid coverage for Spravato is generally available to adults with TRD who have not responded to at least two other antidepressants.
  • What services are covered? Medicaid coverage for Spravato typically includes the cost of the medication, as well as the cost of administration by a healthcare provider.
  • Where can Spravato be administered? Spravato is typically administered in a healthcare provider’s office or clinic. It is not available for home use.
  • How often is Spravato given? Spravato is typically given once or twice a week for the first four weeks of treatment. After that, the frequency of administration may be reduced.
  • How long does Spravato treatment last? The length of Spravato treatment varies from person to person. Some people may only need a few months of treatment, while others may need longer-term treatment.

Medicaid Coverage by State

The following table shows Medicaid coverage for Spravato by state. Please note that this information is subject to change, so it is important to check with your state Medicaid program for the most up-to-date information.

AlabamaNot covered
AlaskaNot covered
ArizonaNot covered
ArkansasNot covered
GeorgiaNot covered
HawaiiNot covered
IdahoNot covered
IndianaNot covered
IowaNot covered
KansasNot covered
KentuckyNot covered
LouisianaNot covered
MississippiNot covered
MissouriNot covered
MontanaNot covered
NebraskaNot covered
NevadaNot covered
New HampshireCovered
New JerseyCovered
New MexicoNot covered
New YorkCovered
North CarolinaCovered
North DakotaNot covered
OhioNot covered
OklahomaNot covered
Rhode IslandCovered
South CarolinaNot covered
South DakotaNot covered
TennesseeNot covered
TexasNot covered
UtahNot covered
West VirginiaNot covered
WyomingNot covered

Eligibility Criteria for Medicaid Coverage of Spravato

To determine whether Spravato is covered by Medicaid, individuals must meet certain eligibility criteria. These criteria may vary among states, but generally include the following:

  • Age: Individuals must be 18 years of age or older.
  • Income: Individuals must meet income guidelines set by the state.
  • Residency: Individuals must be residents of the state in which they are seeking coverage.
  • Disability: Individuals must have a disability that meets the Social Security Administration’s (SSA) definition of disability.
  • Citizenship: Individuals must be U.S. citizens or qualified non-citizens.

Coverage Variations Among States

The coverage of Spravato under Medicaid can vary among states. Some states may cover the drug for all eligible individuals, while others may have restrictions or limitations on coverage. These variations can include:

  • Prior Authorization: Some states may require prior authorization from the state Medicaid agency before Spravato can be prescribed.
  • Limits on Dosage: Some states may limit the dosage or frequency of Spravato that can be prescribed.
  • Restrictions on Providers: Some states may restrict the types of providers who can prescribe or administer Spravato.
  • Cost-Sharing Requirements: Some states may require individuals to pay a co-payment or coinsurance for Spravato.
StateCoveragePrior AuthorizationLimits on DosageRestrictions on ProvidersCost-Sharing Requirements
CaliforniaCovered for all eligible individualsNoNoNoNo
FloridaCovered for all eligible individualsYesYesYesYes
TexasNot coveredN/AN/AN/AN/A

Spravato Coverage Under Medicaid

Spravato, a medication used to treat treatment-resistant depression, is covered by Medicaid in some states. However, prior authorizations and specific documentation may be required to access this coverage.

Prior Authorizations

Many states require prior authorization before Medicaid will cover Spravato. This involves obtaining approval from the state Medicaid agency or an insurance company contracted with Medicaid. The process for obtaining prior authorization varies from state to state and may include:

  • Submitting a prior authorization request form, which can typically be downloaded from the Medicaid agency’s website.
  • Providing supporting documentation, such as medical records, to demonstrate the medical necessity of Spravato.
  • Waiting for a decision from the Medicaid agency or insurance company, which may take several days or weeks.

Documentation Requirements

In addition to prior authorization, Medicaid may also require specific documentation to support the medical necessity of Spravato. This documentation may include:

  • A diagnosis of treatment-resistant depression.
  • A history of failed treatments for depression, such as antidepressant medications, psychotherapy, or electroconvulsive therapy (ECT).
  • A treatment plan that includes Spravato and explains how it will be used in combination with other treatments.

Medicaid Coverage for Spravato by State

The following table provides an overview of Medicaid coverage for Spravato in each state:

StateMedicaid CoveragePrior Authorization Required

It’s important to note that this table is for illustrative purposes only and may not be up to date. For the most current information, please contact your state Medicaid agency or visit their website.

Spravato Coverage and Medicaid

Spravato (esketamine) is a nasal spray medication used to treat depression and other mental health conditions. It is often used in conjunction with other antidepressants and therapies.

Medicaid is a government health insurance program that provides coverage to low-income individuals and families. In many states, Medicaid covers the cost of Spravato.

Reimbursement Rates and Payment Processes

  • Medicaid reimbursement rates for Spravato vary from state to state.
  • The average reimbursement rate is $800 to $1,200 per treatment.
  • Medicaid pays providers for Spravato treatments in two ways:
  • A monthly payment for each patient receiving Spravato
  • A per-treatment payment
  • The specific payment process for Spravato varies from state to state.
Medicaid Reimbursement Rates for Spravato by State
StateAverage Reimbursement Rate
New York$1,200

If you are interested in getting Spravato treatment, you should talk to your doctor about whether Medicaid will cover the cost.

Thanks so much for joining me today! I hope you found this exploration into the coverage of Spravato by Medicaid helpful and informative. If you have any further questions or want to dive deeper into the complexities of insurance coverage, feel free to drop a comment below, and I’ll do my best to answer them to the best of my ability.

Remember, the world of insurance can be tricky to navigate, but don’t lose hope! Keep checking back for more updates and insights, as the healthcare landscape is constantly evolving. We’ll be here to guide you through the ever-changing maze of insurance policies and coverage. Until next time, stay healthy and informed, my friends!