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Does Medicare Cover Esketamine? Comprehensive Guide [2022]

If you haven’t experienced mental health issues, you may not understand why esketamine is such a big deal.

In 2019, the U.S. Food and Drug Administration approved a nasal spray that shows strong promise to treat depression in adults with treatment-resistant depression — the drug is called esketamine and goes by the brand name Spravato.

Why so much excitement over esketamine?

Let’s dig into that below.

Summary: Is Esketamine Covered By...?

Original Medicare

No, neither Medicare Part A nor Medicare Part B covers self-administered prescription drugs.

Medicare Supplement (Medigap) Insurance

No, Medigap plans do not cover additional services (beyond those covered by  Original Medicare).

Medicare Advantage

No, esketamine is currently not covered by any Medicare Advantage plan.

Medicare Part D

No, esketamine is currently not covered by any Part D prescription drug plan (PDP).

What Is Esketamine?

Esketamine (brand name Spravato) is a nasal spray prescribed to adults with treatment-resistant depression or major depressive disorder with suicidal thoughts.

Researchers believe that depression is caused by a lack of dopamine in the brain that controls mood, behavior, and thought patterns.

Esketamine works by increasing the amount of dopamine in the brain.

Esketamine is notable for how fast it works. While traditional antidepressants (e.g., SSRIs like Prozac) take weeks to show effects, esketamine works in as little as 20 minutes.

Spravato Overview

How much does esketamine cost?

Esketamine is taken in small doses and is self-administered through a nasal spray pump twice per week over 12 weeks.  It must be taken in conjunction with an oral antidepressant.

The monthly cost for therapy with esketamine nasal spray is $4,200.

Does Medicare Cover Esketamine?

To cut to the chase, no matter which part of your Medicare coverage you look at:

Medicare currently does not cover esketamine (for neither major depressive disorder nor chronic pain).

It is not covered as part of Original Medicare (Medicare Part B) or as part of any prescription drug plan (PDP), whether obtained through a Medicare Advantage plan or a Medicare Part D plan.

Why doesn’t Medicare cover esketamine?

Medicare only pays for medically necessary drugs.

Esketamine’s effectiveness needs to be studied further before the drug can be deemed medically necessary by Medicare’s standards.

The good news is that pharmaceutical companies are working to develop a longer-acting version of esketamine that can be given by injection rather than a nasal spray.  If this comes to fruition, there would be two positives:

  1. It would be easier to establish the effectiveness of a longer-acting version, and therefore, it is more likely to be approved by Medicare
  2. It may be covered by Medicare Part B

If you’re surprised to hear #2 above, you’re right — for the most part, Original Medicare does not cover prescription medications.

However, the one exception to this is drugs that a doctor must administer.  If esketamine falls into this category, as many injections do, it would be covered under Medicare Part B.

This means you would be responsible for only 20% of the drug’s cost after you meet the annual deductible ($203 in 2021).  And if you have a Medicare Supplement Insurance plan, your responsibility may fall to 0%!

Does Medicare Cover Other Depression Treatments?

In the meantime, individuals suffering from depression can look to Medicare to cover all of the major existing treatments for depression:

  • Medicare prescription drug coverage (through either a Part D plan or a Medicare Advantage plan) will cover oral antidepressant drugs (e.g., SSRIs like Prozac)
  • Medicare Part B (the outpatient medical insurance portion of Original Medicare) will cover individual and group psychotherapy, as long as a doctor deems it medically necessary

Frequently Asked Questions

Original Medicare (Medicare Parts A & B) does not cover prescription drugs, and therefore, it does not cover Esketamine.

Esketamine works by increasing the amount of dopamine in the part of your brain that controls your mood, behavior, and thought patterns. The

Esketamine is a nasal spray that is taken daily in conjunction with an oral antidepressant.

Conclusion

Esketamine is not covered by Medicare for any condition, whether it be treatment-resistant depression or chronic pain. This goes for Original Medicare (Medicare Part A and Medicare Part B), Medicare Advantage, and Medicare Part D.

However, other treatments for depression that do fall under the umbrella of Medicare coverage include oral antidepressants, individual and group psychotherapy from a mental health specialist if medically necessary.

We hope this guide answered your question as to whether Medicare covers Spravato (esketamine).

If you have any additional questions, leave a comment or send us an email, and we’ll be sure to get back to you within 24 hours.

Warm Regards,
The GetSure Team

  1. U.S. Food & Drug Administration. 

    (March 2019). 

    FDA approves new nasal spray medication for treatment-resistant depression. 

  2. National Library of Medicine. 

    (April 2021). 

    Esketamine: a glimmer of hope in treatment-resistant depression. 

  3. Johns Hopkins School of Medicine. 

    (n.d.). 

    Esketamine for Treatment-Resistant Depression. 

  4. Spravato. 

    (n.d.). 

    Home Page. 

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