April 21, 2022
Carlene MacMillan, MD
Spravato®(esketamine), the novel antidepressant that uses new mechanisms of action in the treatment of major depression in adults, may offer hope to patients who haven’t responded to existing therapies. It’s considered by many to be one of the biggest breakthroughs in depression treatment since Prozac.
This innovative treatment option is FDA-approved, prescribed by a psychiatrist or psychiatric nurse practitioner, and covered by most insurances. It’s also administered in a controlled environment, via nasal spray, under the care and supervision of a registered nurse or trained technician. Because Spravato® is relatively new, your patients will likely have questions about the treatment costs, insurance logistics, and efficacy before they decide to go ahead with scheduling sessions.
Most commercial insurance carriers, Medicare and some managed Medicaid plans cover the cost of Spravato®, aside from the co-pays or insurance deductibles that the patient pays. An initial consultation is usually required, so let patients know your practice will follow up to discuss whether they are qualified for treatment and can receive full or partial insurance coverage. This varies between policies, but many insurance companies require at least two prior trials of antidepressants, and for the patient to take an oral antidepressant during treatment with Spravato®.
Patients who are deemed clinically appropriate for Spravato® treatment may also choose to pay for the medicine privately, without insurance coverage. If the patient’s insurance carrier is in-network for your practice, you can bill their insurance for office visits themselves. However, let patients know office visits will not be covered if their insurance is out-of-network even if their insurance pays for the cost of the drug itself. Patients may be able to submit their office visit claim for out-of-network partial reimbursement if their plan has that option.
Your patients will likely want to know how much they can expect to pay out-of-pocket for treatments. Usually, patients who carry in-network insurance will only have a typical office co-pay for each one of their visits, as long as they also meet their plan deductible and other insurance requirements. Ask patients to contact their insurance to verify benefits coverage and any out-of-pocket costs.
For patients with insurance plans that are out-of-network, your practice will still need to follow the FDA’s RiskEvaluation and Mitigation Strategy (REMS) program for esketamine that dictates treatment times, check-in procedures, and follow-up observation protocols.
Patients with out-of-network insurance coverage may also be able to receive reimbursement for their office visits with you. The codes used to bill for esketamine vary based on who is monitoring the patient during the sessions. Have these patients check with their insurance plan, and inquire specifically about codes 99205, 90792, 99212, 99215, 99417,99415, and 99416.
For your patients who don’t qualify for insurance coverage of Spravato®, be clear that the private cost of the treatment can vary, depending on the market rate at the time of dosage.Typically, Spravato® costs $800 to $900 per dose, in addition to the cost of the patient’s office visits.
Whether you offer financial hardship or single case agreements for Spravato®, let your patients know your practice policy upfront. The Spravato® treatment protocol is expensive, highly regulated, and resource-intensive - so it may not be possible for your practice to offer the treatment on a reduced fee basis.
Single case agreements can be challenging to manage because payment reliability is an issue. There may be some patients who would like to use a self-funded plan through their employer, but we recommend you ask your patient to share the rates for office visits and Spravato®treatments with your practice.
Inform patients that your team will start them off with a comprehensive assessment that usually takes one to two hours depending on the specific clinical situation and policies of your practice.
After the initial consultation, patients can usually expect to have Spravato® appointments twice a week, for at least two hours, for the first month of treatment. During the second month, appointments can usually be scaled back to once a week.
After the second month, continued Spravato®treatment depends on clinical necessity and insurance coverage beyond the two-month window, which can vary significantly across insurance plans.
Let your patients know that everyone’s experience with Spravato® can be a bit different. Some patients say they feel tired and relaxed during treatment sessions, while others have unusual perceptual experiences or dissociative feelings. Assure patients that it’s common to feel a shift in their perspective. They may also experience a sense of increased connection to other people and the world around them.
Get the latest in your inbox