April 21, 2022
Carlene MacMillan, MD
Spravato®(esketamine), the novel antidepressant that uses new mechanisms of action inthe treatment of major depression in adults, may offer hope to patients whohaven’t responded to existing therapies. It’s considered by many to be one ofthe biggest breakthroughs in depression treatment since Prozac.
This innovativetreatment option is FDA-approved, prescribed by a psychiatrist or psychiatricnurse practitioner, and covered by most insurances. It’s also administered in acontrolled environment, via nasal spray, under the care and supervision of aregistered nurse or trained technician.
Because Spravato® isrelatively new, your patients will likely have questions about the treatmentcosts, insurance logistics, and efficacy before they decide to go ahead withscheduling sessions.
1. Willinsurance cover the cost of Spravato® treatment and the in-office visit?
Most commercial insurance carriers, Medicareand some managed Medicaid plans cover the cost of Spravato®, aside from theco-pays or insurance deductibles that the patient pays. An initial consultationis usually required, so let patients know your practice will follow up todiscuss whether they are qualified for treatment and can receive full orpartial insurance coverage. This varies between policies, but many insurancecompanies require at least two prior trials of antidepressants, and for thepatient to take an oral antidepressant during treatment with Spravato®.
Patients who are deemed clinically appropriatefor Spravato® treatment may also choose to pay for the medicine privately,without insurance coverage.
If the patient’s insurance carrier isin-network for your practice, you can bill their insurance for office visitsthemselves. However, let patients know office visits will not be covered iftheir insurance is out-of-network even if their insurance pays for the cost ofthe drug itself. Patients may be able to submit their office visit claim forout-of-network partial reimbursement if their plan has that option.
2. Whatout-of-pocket expenses can be expected related to Spravato® treatment?
Your patients will likely want to know howmuch they can expect to pay out-of-pocket for treatments. Usually,patients who carry in-network insurance will only have a typical office co-payfor each one of their visits, as long as they also meet their plan deductibleand other insurance requirements. Ask patients to contact their insurance toverify benefits coverage and any out-of-pocket costs.
For patients with insurance plans that areout-of-network, your practice will still need to follow the FDA’s RiskEvaluation and Mitigation Strategy (REMS) program for esketamine that dictatestreatment times, check-in procedures, and follow-up observationprotocols.
Patients with out-of-network insurancecoverage may also be able to receive reimbursement for their office visits withyou. The codes used to bill for esketamine vary based on who is monitoring thepatient during the sessions. Have these patients check with their insuranceplan, and inquire specifically about codes 99205, 90792, 99212, 99215, 99417,99415, and 99416.
3. Whatwill the treatment cost if it’s not covered by insurance?
For your patients who don’t qualify forinsurance coverage of Spravato®, be clear that the private cost of thetreatment 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 ofthe patient’s office visits.
4. Arethere specific payment options for patients who have financial hardship?
Whether you offer financial hardship or singlecase agreements for Spravato®, let your patients know your practice policyupfront.
The Spravato® treatment protocol is expensive,highly regulated, and resource-intensive - so it may not be possible for yourpractice to offer the treatment on a reduced fee basis.
Single case agreements can be challenging tomanage because payment reliability is an issue. There may be some patients whowould like to use a self-funded plan through their employer, but we recommendyou ask your patient to share the rates for office visits and Spravato®treatments with your practice.
5. Howlong will the first appointment be?
Inform patients that your team will start themoff with a comprehensive assessment that usually takes one to two hoursdepending on the specific clinical situation and policies of yourpractice.
6. Howoften do patients need to visit the office for Spravato® treatment?
After the initial consultation, patients canusually expect to have Spravato® appointments twice a week, for at least twohours, 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 thetwo-month window, which can vary significantly across insurance plans.
7. Whattype of experience can be expected with Spravato®?
Let your patients know that everyone’sexperience with Spravato® can be a bit different. Some patients say they feeltired and relaxed during treatment sessions, while others have unusualperceptual experiences or dissociative feelings. Assure patients that it’s commonto feel a shift in their perspective. They may also experience a sense ofincreased connection to other people and the world around them.
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