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How insurance covers Spravato®

In the commercial policies we read, getting Spravato (esketamine) covered for treatment-resistant depression runs through prior authorization and a record of the antidepressants you have already tried. Here is what commercial, Medicare, and Medicaid rules say, and what to ask before your first treatment.

By: ZSK ManagementPublished: September 28, 2026Last updated: September 28, 2026Editorial policy

At a glance

  • Spravato is FDA-approved, so insurers publish coverage rules for it. Ketamine injection for depression is off-label, and at least one major insurer calls it investigational.
  • For treatment-resistant depression, the three commercial policies we read all require a record of failed antidepressant trials and a psychiatrist’s involvement (Cigna also accepts another mental health provider), and they limit how long each approval lasts. Their criteria for depression with acute suicidal thoughts are different.
  • The medicine and the supervised observation visit can be billed separately or together, and they can fall under different parts of your coverage.
  • The manufacturer’s savings programs are for commercial insurance only. They do not apply to Medicare or Medicaid.
  • A denial can be appealed. The deadlines depend on the type of coverage.

What Spravato is approved for

Spravato® (esketamine) is a nasal spray. Its FDA label covers two uses in adults: treatment-resistant depression, either on its own or with an oral antidepressant, and depressive symptoms in major depressive disorder with acute suicidal thoughts or behavior, together with an oral antidepressant. Treatment-resistant depression (TRD) means depression that has not improved enough after trying antidepressants. Each insurer below defines how many trials count.

That approval is why insurers have a coverage path for Spravato and usually not for IV ketamine. UnitedHealthcare’s commercial policy, for example, calls ketamine injection for depression and other psychiatric disorders investigational. For the full comparison, see Ketamine vs. Spravato.

The approval comes with limits that shape the bill. Spravato can only be given in a healthcare setting certified in its REMS safety program. You take it there, and a healthcare provider monitors you for at least two hours afterward. Certified pharmacies may dispense it only to certified healthcare settings, never to patients for home use. The manufacturer’s Find a Center tool lists certified centers.

The medicine and the observation visit

According to the manufacturer’s billing guide, Spravato can be covered under a plan’s medical benefit, its pharmacy benefit, or both, depending on the plan. Under the medical benefit, the treatment center usually buys the medicine and bills your plan for it and for the visit. Under the pharmacy benefit, a certified specialty pharmacy sends the medicine to the center, and the center bills only for the observation and monitoring.

Ask the center which benefit your plan uses before your first visit. It changes what you owe and which prior authorization is needed. If coverage is denied under one benefit, the same guide tells providers to check whether the other one was tried.

Commercial insurance: what published policies require

We read the published Spravato policies of three large insurers. All three require approval before you start. Your own plan may use different criteria, especially if your employer pays claims directly. Ask your plan for the policy that applies to you.

Insurer and policyFailed antidepressant trialsPrescriberOther requirementsApproval period
UnitedHealthcare
Medical benefit drug policy 2026D0069Q, effective May 1, 2026		At least two different antidepressants or treatment regimens, at least 8 weeks eachPrescribed by or in consultation with a psychiatristRecords showing a baseline depression rating score; provider or setting certified in the Spravato REMSUp to 12 months; renewal needs documented remission or a positive response
Aetna
Clinical Policy Bulletin 0950, last reviewed February 25, 2026		Two antidepressants from at least two classes, each at the maximally tolerated labeled dose for at least 8 weeks, in the current episode and within the past 5 years, plus a failed trial of augmentation therapy (at least 8 weeks, within the past 5 years) or of evidence-based psychotherapy in the current episodePrescribed by or in consultation with a psychiatristPrecertification required; age 18 or older; severe depression documented by rating scalesInitial period not stated; continuation covered for 6 months with documented improvement
Cigna
Drug coverage policy IP0220, effective June 1, 2026		At least two antidepressants from different classes, at least 6 weeks each in the current episode, with 25% improvement or lessPrescribed by or in consultation with a psychiatrist or a mental health providerPrior authorization required; age 18 or older; prescriber checks the state prescription drug monitoring program6 months to start, then 1 year at a time with a beneficial response

All three policies ask for records, not just a diagnosis. Keep a list of every antidepressant you have tried, with doses and dates, and ask your prescriber to record your depression rating scores before you start.

Aetna’s policy adds an exclusion the table does not show: people with a moderate or severe substance or alcohol use disorder who are not receiving treatment for it are not eligible.

The table covers treatment-resistant depression. For depressive symptoms with acute suicidal thoughts or behavior, all three policies use separate criteria that do not require failed antidepressant trials. Each requires an oral antidepressant alongside Spravato. Aetna also requires the prescriber to state that, without Spravato, you would need psychiatric hospitalization within 24 to 48 hours, and it covers up to 4 weeks of treatment. Cigna approves 2 months, enough for a 4-week course. Spravato’s label says it has not been shown to prevent suicide and does not replace hospitalization when it is needed. If someone may act on thoughts of suicide, call 911 now. You can also call or text 988.

Manufacturer savings programs

Johnson & Johnson, which makes Spravato, runs two programs for people with commercial insurance, one for the medicine and one for the observation visit. Each has its own terms, and both exclude Medicare, Medicaid, and other government-funded coverage.

  • Savings Program (medicine). Eligible people age 18 or older with commercial insurance, including Marketplace plans, may pay as little as $10 per treatment for the medicine, up to an annual maximum. It does not cover the observation visit. You must enroll before your first treatment. The terms say the benefit may be reduced for plans with accumulator or maximizer designs, and people in plans that partner with SaveOnSP are not eligible, except where prohibited by law. Monthly maximums may also apply. The terms expire at the end of each calendar year, and the program can change or end without notice. Program terms.
  • Observation Rebate Program (observation visit). Eligible people with commercial insurance can get a rebate of their out-of-pocket cost for the observation of each treatment, up to an annual maximum, after paying the provider. It does not cover the medicine, and it is not valid for residents of Massachusetts, Minnesota, or Rhode Island. Program terms.

Medicare

Since January 2020, Medicare has used two billing codes for Spravato treatment in a clinic. G2082 and G2083 each cover the office visit, the esketamine, and two hours of observation. G2082 is for doses up to 56 mg and G2083 for doses above 56 mg. When the center supplies the medicine, Original Medicare pays for the medicine, the visit, and the observation together under one of these codes, not as separate charges. In CMS’s October 2026 code file, the separate drug code J0013 is listed as not payable by Medicare, and coverage of the two visit codes is left to the judgment of the regional Medicare contractor.

Both codes are paid under the Medicare Physician Fee Schedule, which is part of Part B. In 2026, you pay the first $283 of Part B costs each year. After that, Medicare.gov says you usually pay 20% of the Medicare-approved amount, as long as the provider accepts that amount as full payment.

Medicare Advantage plans may handle Spravato differently from Original Medicare; the manufacturer’s billing guide notes they can cover it under a different benefit. Ask the plan in writing. The manufacturer savings programs above do not apply to anyone using Medicare. Your State Health Insurance Assistance Program (SHIP) offers free one-on-one counseling on Medicare coverage; find yours at shiphelp.org.

Medicaid, state by state

Each state’s Medicaid program decides how it covers Spravato, usually through a preferred drug list and prior authorization criteria. On these lists, non-preferred does not mean not covered. It usually means you need prior authorization, often after trying preferred drugs. A drug that is missing from a state’s drug list is not necessarily excluded. Some states cover Spravato through separate criteria, such as their rules for drugs given in a clinic, so read the state card. Many Medicaid members are in managed care plans, and some states let those plans use their own criteria.

The table covers the 16 states and Washington, DC in our East Coast guide. We checked each document on September 27, 2026. These lists change often, so open the state document or the full state card before you rely on it.

StateMedicaid documents on SpravatoMain document
MaineNon-preferred; prior authorization requiredMaineCare Preferred Drug List, effective July 1, 2026
New HampshireNon-preferred; additional clinical prior authorizationNew Hampshire DHHS Fee-for-Service Medicaid Preferred Drug List, effective July 1, 2026
VermontNon-preferred; prior authorization requiredDepartment of Vermont Health Access — Vermont Preferred Drug List and Drugs Requiring Prior Authorization, updated August 1, 2026
MassachusettsPrior authorization requiredMassHealth Drug List — Table 17: Antidepressants, last revised July 2026
Rhode IslandNon-preferred; prior authorization required (manual PA)Rhode Island Medicaid Fee for Service Preferred Drug List, updated June 16, 2026
ConnecticutNot preferred; new prescriptions require prior authorizationConnecticut Medical Assistance Program — Current PA Criteria, including Medically Necessary Spravato Prior Authorization (undated)
New YorkNot in the preferred-drug tables; drug utilization review criteria applyNYRx Preferred Drug Program and Drug Utilization Review parameters, revised September 14, 2026
New JerseyNo single statewide drug list found; ask your NJ FamilyCare planNew Jersey Division of Medical Assistance and Health Services — 2024 State Parity Evaluation (pharmacy coverage through managed care plans)
PennsylvaniaNon-preferred; prior authorization requiredPennsylvania Department of Human Services — Statewide Preferred Drug List, effective January 2026 (v14)
DelawareListed with clinical criteria (fee-for-service)Delaware Medicaid Preferred Drug List, effective September 7, 2026
MarylandNon-preferred; prior authorization requiredMaryland Medicaid Pharmacy Program — Preferred Drug List, updated August 6, 2026
Washington, DCPrior authorization required (fee-for-service)DC Department of Health Care Finance — Pharmacy Preferred Drug List, effective September 8, 2026
VirginiaNot on the drug list; separate physician-administered drug criteriaVirginia DMAS — Appendix B: Physician Administered Drug (PAD) Criteria, effective July 23, 2026
North CarolinaNot on the drug list; listed in the physician-administered drug catalogNC Medicaid — Physician Administered Drug Program catalog (September 17, 2026 version)
South CarolinaNot on the drug list; no official Spravato document found; ask your planSouth Carolina Medicaid single Preferred Drug List, effective September 1, 2026
GeorgiaNon-preferred; prior authorization requiredGeorgia Medicaid/PeachCare Preferred Drug List, effective September 1, 2026
FloridaNot on the drug list; separate prior authorization criteriaFlorida Medicaid — Spravato™ (esketamine) Prior Authorization Criteria, revised September 16, 2026

If your plan says no

Ask for the reason for the denial in writing, because it tells you what the appeal has to answer. Then ask your prescriber for a letter explaining why you need Spravato. How you appeal depends on your coverage.

  • Employer, individual, and Marketplace plans. File an internal appeal with the insurer within 180 days of the denial notice. For a treatment you have not received yet, the insurer must decide within 30 days, and faster in urgent cases. If the insurer upholds the denial, you can request an external review by an independent reviewer within four months. The insurer must accept that reviewer’s decision. Older “grandfathered” plans may not have to offer these appeal rights, so check your plan documents. See HealthCare.gov on internal appeals, external review, and grandfathered plans.
  • Medicaid. Federal rules require the state to offer a hearing when you disagree with a prior authorization decision. If you are in a Medicaid managed care plan, you appeal to the plan first, within 60 days of its notice, and then you can ask for a state fair hearing if the plan upholds its decision.
  • Medicare. Original Medicare generally has five levels of appeal. Medicare Advantage and drug plans must tell you in writing how to appeal. See Medicare.gov.

Questions to ask the treatment center

  1. Is Spravato covered under my medical benefit, my pharmacy benefit, or both?
  2. Will you request the prior authorization? What records do you need from me or my other doctors?
  3. What will I owe for the observation visit, separate from the medicine? Will that change after I meet my deductible?
  4. If I have commercial insurance, should I enroll in the manufacturer’s programs before my first treatment?
  5. When does the approval end, and what do you send to renew it?

For other costs, including cash prices for IV ketamine, see cost and insurance. To judge the center itself, see how to choose a clinic.

Have a question about your coverage? and we’ll reply with general information. We can’t tell you what your plan will approve, and we don’t share your request with any provider.

Sources