Are Ketamine Infusions Covered by Insurance?

Ketamine is known to have some antidepressant properties, and a ketamine oral medication and nasal spray are approved by the Food and Drug Administration (FDA) for treatment-resistant depression. The generic version of the ketamine-derivative medication (esketamine) and the name brand equivalent (Spravato) are approved for use in conjunction with an oral antidepressant for adults who have unsuccessfully tried other treatments for depression.

Esketamine is a slightly altered version of ketamine. Because the FDA has only approved ketamine for use as an anesthetic, that means ketamine infusion to treat depression is not technically FDA approved and therefore isn’t likely to be covered by Medicare.

Because esketamine is a separate drug that has been approved for depression treatment, Medicare may cover it for depression in certain circumstances if specific conditions are met.

You should talk with your doctor about whether Medicare will cover your depression treatment before you undergo esketamine or Spravato treatment. If you have a Medicare Part D prescription drug plan or a Medicare Advantage plan that includes prescription drug coverage, be sure to check with your plan carrier to find out if your plan covers esketamine or Spravato for depression.

What Is a Ketamine Infusion for Depression?

Just because ketamine infusion (that is, ketamine treatment through an IV) is not FDA-approved for depression doesn’t mean it can’t be legally performed or effective. Ketamine infusion can be used “off-label” for depression treatment, meaning the drug itself is FDA-approved but not for the specific treatment it’s being used for. 

Ketamine infusion has the ability to work faster and treat more severe cases of depression than antidepressant medication are capable of, while also showing fewer side effects. The infusion is administered through an IV in the arm and the effects can last days or even weeks. Patients often receive tapered treatments, meaning they undergo multiple infusions early on before moving on to less frequent sessions.

There are various clinics that offer ketamine infusion for depression. Because it is not a FDA-approved treatment, most insurances do not cover it and patients generally pay for the service out of pocket.  

Ketamine infusion is also sometimes administered by psychiatrists on an experimental basis for people with severe depression or suicidal thoughts. 

What is Esketamine?

FDA approval requires drugs to undergo trial periods to prove they are safe and effective, which can take years to complete and cost a considerable amount of money. Because ketamine was approved by the FDA as a generic non-patented drug, pharmaceutical companies have little incentive to invest the millions of dollars and years of work required to get FDA approval of ketamine for depression treatment.

This is the primary reason why esketamine – which is a slightly chemically altered version of ketamine that Johnson & Johnson was able to get approved by the FDA for depression treatment – has been a more attractive version of the drug for pharmaceutical development.

What Does Medicare Cover for Depression?

While Original Medicare (Medicare Part A and Part B) is unlikely to cover ketamine infusion for depression, it does provide coverage of various other depression treatments. 

• Medicare Part B covers one depression screening per year. Part B also covers other mental health care treatments received in an outpatient setting, such as therapy, family counseling and diagnostic testing.
  
  
• Inpatient mental health care is covered by Medicare Part A. This includes any mental health treatment you receive as an inpatient at a general hospital or at a hospital that specifically offers mental health treatment.

Behavioral health integration services and substance use disorder services can also be covered by Medicare.

Does Medicare Cover Depression Medications?

Medicare beneficiaries may be able to get coverage for their depression medication and treatment – which could include esketamine or Spravato – if they have a Medicare Part D prescription drug plan or a Medicare Advantage Prescription Drug plan that offers coverage for the drug.

Esketamine and Spravato are typically administered by a doctor or other health care professional, which means you most likely cannot fill a prescription for either drug at a retail pharmacy. Be sure to check with your Medicare plan carrier directly to find out if your plan will cover esketamine for depression.

How Does Ketamine Affect the Brain?

Racemic ketamine is the type of ketamine most often used for infusions (IV treatment). It’s a mixture of the “R” and “S” ketamine molecules and was approved by the FDA many years ago as an anesthetic. The doses that are infused to treat depression are much smaller doses than those injected for anesthesia. 

While antidepressants work as they enter the body, ketamine that is infused for depression actually works as it exits the body, which is why just one session has such long-lasting potential. 

It is theorized that ketamine prompts the regrowth of broken connections between brain cells that are involved in mood. Ketamine acts as a bonding agent in the spaces of the brain between neurons and helps the neurons communicate with each other along new pathways. This process is known as synaptogenesis and affects mood, cognition and thought patterns. 

Ketamine may also reduce inflammation, which has been linked to mood disorders. 

Side Effects of Ketamine Infusion

Ketamine infusion may lead to the following side effects:

• High blood pressure
• Nausea or vomiting 
• Dissociation or out-of-body experiences
• Perceptual disturbances such as feeling like time is speeding up or slowing down, blurry vision and stimulating noises, colors or textures

Ketamine has addictive properties that don’t disappear when the drug is infused. Those who respond well to ketamine infusion generally experience positive results within the first couple of sessions. If no response is triggered during the first few infusions, any further infusions are unlikely to help. 

Ketamine Infusion Resources

Consult the following resources for more information about ketamine infusion for depression. 

• Ketamine for major depression – Harvard Medical School
• Ketamine Infusion Therapy – American Psychiatric Nurses Association
• Ketamine May Relieve Symptoms of Treatment-Resistant Depression – Massachusetts General Hospital 
• Single, Repeated, and Maintenance Ketamine Infusions for Treatment-Resistant Depression: A Randomized Controlled Trial – Focus