Your guide to Medicaid coverage for Spravato®: Eligibility, cost and treatment options

Navigating mental health treatment can feel confusing, especially when you’re exploring medications that require special approval or clinical monitoring. If you’re considering Spravato® (esketamine) as part of your depression treatment plan, understanding your Medicaid coverage is an important first step. 

Medicaid coverage for Spravato® is often available, but the rules can vary greatly from state to state. Medicaid is a program funded by both the state and federal governments, and each state sets its own rules about which medications and treatments it will cover. Understanding these specific rules is the key to starting your treatment journey. 

If you or a loved one has Medicaid and is looking for safe, effective depression treatment, this guide breaks down the basics in a clear and supportive way so that you can feel empowered when making decisions about your care. 

Key requirements for Medicaid Spravato® coverage

Because Spravato® is a controlled medication with strict safety standards, Medicaid requires several eligibility steps. While each state creates its own rules, most Medicaid programs follow similar guidelines.

• A qualifying diagnosis

Spravato® is FDA approved for two serious conditions:

• Treatment-resistant depression (TRD) in adults
• Major depressive disorder (MDD) with suicidal thoughts or actions

Up to 30% of U.S. adults with depression don’t respond to first-line treatments, which is one reason Spravato® has become an important option for so many people. 

• Previous treatment attempts

Most Medicaid plans require documentation that you’ve tried, and your symptoms didn’t improve with, at least two different antidepressant medications. Some states may also request documentation of psychotherapy participation. 

This requirement helps Medicaid ensure that Spravato® is being used when other treatments haven’t been enough. 

• Treatment at a REMS-certified location

Spravato® must be administered in a clinic that participates in the FDA’s Risk Evaluation and Mitigation Strategy (REMS) program. This ensures that your provider is trained to safely administer and monitor the medication. 

A REMS-certified location must have:

• Clinicians trained in administering Spravato®
• Equipment for monitoring blood pressure and vital signs
• A comfortable, safe room
• Staff available for the entire two-hour monitoring period after each dose

• Prior authorization

Almost all Medicaid plans require prior authorization, or preapproval, before you can begin treatment. This typically includes:

• Clinical notes detailing your diagnosis
• Medication history
• Documentation of symptom severity
• Confirmation that the clinic is REMS certified

Approval times can vary, but often range from three to 14 business days, depending on the state. 

• Age requirements

Spravato® is FDA approved for adults aged 18 and older. Medicaid plans follow this rule. 

• Exclusions and limitations

States may exclude Spravato® for:

• Off-label uses
• People who are pregnant or breastfeeding
• People with uncontrolled high blood pressure or certain medical conditions
• Individuals unable to stay in the clinic for the two-hour observation period

Your provider can help determine whether Spravato® is medically appropriate for you.

Understanding the cost of Spravato® with Medicaid

One of the biggest questions people may have is, “How much will Spravato® cost me?” The answer depends heavily on your state’s Medicaid rules and whether you have standard Medicaid, managed Medicaid or an expanded Medicaid plan. 

Depending on your specific coverage, you may have:

• A small copay; some states charge $0 for mental health services
• Coinsurance, usually a small percentage
• A deductible, depending on your type of Medicaid plan
• No out-of-pocket cost at all, which is common in many states

The Spravato withMe program offered by the manufacturer may help with coordination of benefits and support, but doesn’t typically cover copays for Medicaid beneficiaries due to federal regulations. Still, the program can help you:

• Understand coverage
• Track authorizations
• Coordinate benefits with your clinic
• Navigate treatment logistics

Your provider’s clinic, especially one experienced with Medicaid, can verify your benefits before your first dose. 

What to expect during Spravato® treatment

Because Spravato® is taken as a nasal spray and can have dissociative effects, it must be used in a clinical setting with trained professionals. During Spravato® treatment, you may expect:

• A controlled and supportive environment

A qualified psychiatrist or psychiatric mental health nurse practitioner oversees your care. The clinical team guides you through each dose and monitors you throughout your visit. 

• Two-hour monitored sessions

After you administer the medication under supervision, you relax in a comfortable treatment area while the team monitors:

• Your blood pressure
• Your heart rate
• Your mental status
• Potential side effects

Many people report feeling calm, introspective or drowsy after treatment. These effects are expected and temporary. 

• A tailored treatment plan

Spravato® is most effective when combined with an oral antidepressant and, ideally, psychotherapy. Research has shown that combining medication and psychotherapy can improve outcomes compared to medication alone. 

• Regular follow-ups

You’ll meet with your provider frequently during the first month to track progress and update your care plan. 

Find hope with Spravato® and your Medicaid benefits at Psychiatry Treatment Centers

Spravato® can be a life-changing option for people living with treatment-resistant depression or major depression with suicidal thoughts, and Medicaid coverage makes this treatment accessible to many who need it most. While eligibility rules vary by state, understanding the requirements can help you feel more confident as you explore treatment options. 

At Psychiatry Treatment Centers, we’re committed to making advanced depression care available and supportive for every person. We offer Spravato®, transcranial magnetic stimulation (TMS) and comprehensive psychiatric services, and our team is here to help guide you through the Medicaid approval process with clarity and compassion. 

Reach out to our team by phone today for more information or to schedule an initial appointment. You can also book your initial appointment online now.