by Russell Noga | Updated January 21st, 2024
Are you considering Spravato for treatment-resistant depression and need to know if Medicare will help cover the costs? The answer is, does Medicare cover Spravato?
Yes, Medicare does cover Spravato, but eligibility criteria apply. In this article, we unpack the specifics of Medicare’s coverage for Spravato, ensuring you walk away with a clear understanding of your potential benefits and next steps.
- Medicare coverage for Spravato, used to treat treatment-resistant depression, includes the medication cost, doctor’s visits, and necessary monitoring, but eligibility requirements based on diagnosis and participation in Medicare Part B must be met.
- Spravato treatment, which must be administered in a healthcare facility under supervision, has a structured process including an initial phase with twice-weekly treatments and a maintenance phase with less frequent administration.
- Financial assistance for the costs associated with Spravato treatment is available from various programs for eligible patients, helping to cover expenses not covered by Medicare or for those with financial hardship.
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Medicare and Spravato: A Comprehensive Guide
Medicare, as a federal health insurance program, is a lifeline for many Americans. When it comes to mental health treatment, Medicare coverage extends to include a range of mental health services, such as treatments like Spravato.
This prescription medication, approved by the Food and Drug Administration (FDA), has shown efficacy in treating treatment-resistant depression (TRD) and addressing mental health issues.
Certain prerequisites must be met to access Medicare coverage for Spravato. First, your doctor must recommend Spravato as part of your treatment regimen. Second, you must find a pharmacy within your plan’s network that can dispense the medication.
This raises the question of eligibility for Medicare coverage of Spravato.
Eligibility Requirements for Spravato Coverage
Medicare coverage for Spravato hinges on the diagnosis of treatment-resistant depression (TRD), a type of major depressive disorder. This means that if you have been battling depression and have not seen substantial improvement with other treatments, you could be eligible for Medicare coverage of Spravato.
However, Medicare Part B plays a significant role in this regard. It provides coverage for Spravato treatment for eligible patients, including:
- The cost of the medication
- The doctor’s office visit
- Necessary monitoring
- The Spravato starter kit with the nasal spray device and other supplies.
This leads us to the specific role of Medicare Part B in providing Medicare Part B coverage for Spravato.
Medicare Part B and Spravato
Every aspect of Spravato treatment, from the medication itself to the doctor’s office visit and necessary monitoring, falls under the coverage of Medicare Part B. This is a game-changer for patients grappling with TRD, as it significantly reduces the financial burden of treatment.
Medicare Part B covers 80% of the cost of Spravato treatment, leaving the patient accountable for the remaining 20%. For example, a typical doctor’s visit for administering Spravato costs approximately $150, which means an out-of-pocket cost of around $30 for the patient.
In addition, the Medicare Part B plan will cover the expenses for the Spravato starter kit, comprising the nasal spray device and other necessary supplies. This coverage is beneficial for eligible recipients seeking treatment.
The Spravato Treatment Process
Spravato treatment is a structured process. It begins with the patient administering the Spravato nasal spray under the guidance of a healthcare provider at an accredited treatment center. This is usually done in conjunction with an oral antidepressant.
The treatment process is divided into two phases: the initial phase and the maintenance phase.
During the initial phase, which spans the first month, treatment sessions are administered twice a week.
This frequency changes to once weekly from weeks five to eight. Beyond the eighth week, the treatment may be scheduled every two weeks or continued every week, depending on the patient’s response to the medication.
Now, let’s explore the different stages of the Spravato treatment process in more detail.
Initial Consultation and Assessment
The journey towards Spravato treatment begins with an initial consultation. The main objective is to evaluate your mental health status and ascertain Spravato’s suitability. The healthcare provider will assess the suitability of Spravato/esketamine, review your medical history and current symptoms, and check for any contraindications.
To prepare for this consultation, you should:
- Compile your medical history
- List your current medications
- Note any known allergies
- Be ready to discuss any substance use
This session typically lasts about an hour.
Once the initial consultation is completed, the process moves on to the administration of the Spravato nasal spray.
Administration of Spravato Nasal Spray
The administration of Spravato is straightforward. It is conducted in a doctor’s office or clinic under the close supervision of a healthcare professional. The patient should follow these steps:
- Close one nostril.
- Firmly press the plunger to release the spray.
- Inhale slowly through the nose while keeping the other nostril closed.
- Repeat the process for the second nostril.
Following the nasal spray administration, the process proceeds to the stage of ongoing care and follow-up appointments.
Ongoing Care and Follow-Up Appointments
Spravato treatment doesn’t end with the administration of the nasal spray. Follow-up appointments are crucial for monitoring the patient’s progress and evaluating the treatment’s effectiveness.
The frequency of these appointments changes as the treatment progresses, with two appointments per week for the first four weeks, followed by once-weekly appointments from weeks five to eight, and then either every two weeks or once weekly thereafter.
During these sessions, the healthcare provider closely monitors the patient’s vital signs and mental status.
Financial Assistance Programs for Spravato Treatment
While Medicare coverage significantly reduces the cost of Spravato treatment, some patients may need additional financial assistance. Thankfully, several organizations offer such support. The SPRAVATO withMe Care Navigator program, the Johnson & Johnson Patient Assistance Foundation, and the HealthWell Foundation are among those that provide financial assistance for Spravato treatment.
There are no specific income requirements to qualify for these programs. Patients can seek assistance through the following programs:
- SPRAVATO withMe Savings Program, which covers medication costs
- NeedyMeds program
- Spravato’s patient support services, which offer basic product information, motivational encouragement, and affordability support through a restricted program called Spravato Assistance.
The financial aid decisions for Spravato treatment take into consideration:
- patient assistance programs
- insurance coverage
- payment options
Having addressed financial concerns, it’s time to compare Spravato with other depression treatments.
Comparing Spravato with Other Treatments for Depression
Depression is a complex mental health condition, and its treatment involves various approaches. Common treatments include medication, therapy, and self-help strategies. However, not all treatments work for everyone, which is where Spravato comes into the picture.
Spravato (esketamine) nasal spray has proven to be effective, particularly in adults with treatment-resistant depression (TRD). But as with any medication, it’s essential to understand the benefits and potential limitations of Spravato.
Benefits of Spravato
One of the most significant benefits of Spravato is its effectiveness in treating depression, especially in TRD patients. It has been observed to have a positive impact, with a 40-60% efficacy rate for individuals with TRD.
Furthermore, Spravato demonstrates the following therapeutic effects:
- Faster onset of action compared to other depression treatments, usually within a few weeks of consistent treatment
- Reduced risk of suicide
- Relief of depression symptoms
- Increased likelihood of response and remission in patients with TRD
Nevertheless, it is also crucial to be mindful of any potential limitations and concerns related to Spravato, as well as conducting a proper risk evaluation.
Limitations and Concerns
While Spravato has proven to be a promising treatment option, it’s not suitable for everyone. For instance, patients with aneurysmal vascular disease or those for whom an increase in blood pressure or intracranial pressure would pose serious risks should not use Spravato. Spravato also interacts with certain diseases, alcohol, and other medications, which could limit its suitability for some patients.
Long-term risks associated with Spravato treatment can include:
- Elevated heart rate
Having weighed the benefits and limitations of Spravato, it’s time to explore how to navigate insurance and Medicare when seeking Spravato treatment.
Navigating Insurance and Medicare for Spravato Treatment
Securing Medicare insurance and Medicare coverage for Spravato treatment can be a complex process. While Medicare provides coverage if your doctor recommends Spravato as part of your treatment regimen, obtaining coverage requires understanding and navigating the healthcare system.
Communication with healthcare providers is vital in this process, as is understanding the relevance of HCPCS and CPT codes in Spravato treatment. However, challenges can arise, including:
- restricted coverage for mental health treatment
- lack of uniform practices for insurance reimbursement determination
- the need for financial aid to handle out-of-pocket costs.
Communicating with Healthcare Providers
Open and transparent communication with your healthcare provider is essential when seeking Spravato treatment. Providers play a critical role in coordinating care, maintaining an open line of communication with referring providers, and adhering to the prescribed treatment plan.
Patients can effectively communicate their concerns about Spravato by engaging in discussions with their healthcare provider. They can also seek answers to commonly asked questions about Spravato and access patient brochures and discussion guides for further information. It’s also important to ask your healthcare provider about the information you should disclose before starting Spravato, the differences between Spravato nasal spray and ketamine infusion, and how Spravato interacts with other medications.
Healthcare providers are responsible for disclosing important information regarding Spravato treatment, such as the need to check for signs of abuse and dependence before and during treatment.
Understanding HCPCS and CPT Codes
HCPCS and CPT codes play a pivotal role in medical billing and are essential for the Medicare coverage of Spravato treatment. They ensure precise billing and coding for the drug when it is administered at healthcare facilities enrolled in Medicare.
While CPT codes document medical, surgical, and diagnostic procedures performed by healthcare professionals, HCPCS codes document medical services and procedures for Medicare, Medicaid, and other health insurance programs. Medicare and other insurance companies use HCPCS codes for services, supplies, and equipment not specified by CPT codes. These codes assist healthcare providers in selecting suitable codes for claims, considering the patient’s condition, the services rendered, and the necessary monitoring during treatment.
Finding a Spravato Treatment Center That Accepts Medicare
After navigating the insurance and Medicare landscape, the subsequent step is to find a Spravato treatment center that accepts Medicare. There are several resources available, including:
- The SAMHSA National Helpline
- The Spravato website
- Anew Era Psychiatry
- Online directories such as the official Spravato website and LifeStance
These resources provide information on Spravato treatment centers that accept Medicare.
If there are no treatment centers accepting Medicare in your area, you can reach out to service providers affiliated with Spravato, such as Spravato withMe, to inquire about insurance coverage and cost support options. Alternatively, you can discuss alternative treatments with your healthcare provider. Your healthcare provider can also guide you in finding a certified Spravato treatment center that accepts Medicare and may have knowledge of local options and procedures.
In summary, Spravato offers a promising solution for those struggling with treatment-resistant depression, with Medicare playing a significant role in making this treatment more accessible. Understanding Medicare’s coverage, the treatment process, the benefits and limitations of Spravato, and navigating insurance and Medicare for Spravato treatment are all crucial steps in this journey.
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Frequently Asked Questions
Is Spravato covered under Part B?
Yes, Spravato is covered under Part B through bundled G codes 2082 and 2083, which cover both the drug and treatment visit.
How much does Spravato cost without insurance?
Without insurance, the cost of Spravato nasal spray is approximately $780 for a supply of 2 sprays, varying by pharmacy. This price is for cash-paying customers and does not apply to insurance plans.
What qualifies you for Spravato?
To qualify for Spravato, you must be at least 18 years old and have a diagnosis of Treatment-Resistant Depression (TRD), with no significant improvement after trying at least 2 different classes of antidepressants for at least 4 weeks each.
How much does Spravato reimburse?
Spravato reimburses up to a maximum program benefit of $8150 per calendar year, with savings that may apply to your co-pay, co-insurance, or deductible. However, the program does not cover the cost of treatment observation.
Speak to the Professionals about Medigap Plans and Original Medicare Deductibles
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Russell Noga is the CEO and Medicare editor of Medisupps.com. His 15 years of experience in the Medicare insurance market includes being a licensed Medicare insurance broker in all 50 states. He is frequently featured as a featured as a keynote Medicare event speaker, has authored hundreds of Medicare content pages, and hosts the very popular Medisupps.com Medicare Youtube channel. His expertise includes Medicare, Medigap insurance, Medicare Advantage plans, and Medicare Part D.