Does Medicare Cover Esketamine? 

Feeling sad is a normal emotion we all experience now and again. Sadness is distinguishable from clinical depression. Also known as major depression or major depressive disorder, depression significantly impacts everyday feelings, thoughts, behaviors, sleep, eating habits and work capacity.

The spectrum of symptoms across different types of depression ranges from feeling hopeless, irritable, frustrated and worthless to having suicidal thoughts. Physical pain, overeating and digestive ailments may also be symptomatic of depression. According to the National Institute of Mental Health (NIMH), your doctor may present a depression diagnosis if symptoms occur most of the day, almost every day, for at least two weeks.

Treatment for depression

Depression is a treatable disorder, and the prospect of successful results increases with early intervention. Your doctor may prescribe medication, psychotherapy or both. The NIMH explains that there is no one-size-fits-all approach. Some people experience a trial-and-error period before finding the most effective treatment. If you have tried at least two medications for depression and do not improve, you may have treatment-resistant depression.

In March 2019, the U.S. Food and Drug Administration (FDA) approved Spravato for treatment-resistant depression. The generic name of the drug is esketamine. Spravato is a nasal spray for adults with two types of major depressive disorder, suicidal thoughts or behaviors and insufficient response to at least two oral antidepressants.

FDA requirements for esketamine

Spravato is a Schedule III controlled substance, defined by the U.S. Drug Enforcement Administration (DEA) as a drug “with a moderate to low potential for physical and psychological dependence.” Due to the potential risks associated with the drug’s application, the FDA requires adherence to a safety program known as Risk Evaluation and Mitigation Strategy (REMS).

The REMS objective is to promote safe practices through prevention, management and education to reduce the risk of severe events caused by the drug. In compliance with REMS, Spravato dispensing and administering can only occur in a REMS-certified healthcare setting like your doctor’s office or a clinic. A qualified healthcare practitioner must monitor you for at least two hours to manage any side effects.  

Medicare Part B drug benefits

Part D covers self-administered pharmaceuticals, and Part B covers drugs you get in a doctor’s office or hospital outpatient department. Eligibility for esketamine coverage falls under Medicare Part B because it is only available in an outpatient healthcare setting.

Your cost-sharing is 20% of the Medicare-approved amount after meeting the annual Part B deductible. Hospital outpatient facilities often charge a copayment as well. If you have Medicare Supplement insurance, you are eligible for all or part of the Part B coinsurance or copayment, depending on your Medigap policy.

Medicare coverage for depression

If you use a Medicare-participating provider, Part B covers an annual depression screening at no cost. Your doctor must perform the screening in a primary care setting, such as a doctor’s office.

Part B also covers mental healthcare to treat depression and anxiety. Covered services include psychotherapy in an outpatient setting. You pay 20% coinsurance and the Part B deductible. Part A covers mental health services if you are a hospital inpatient.

How to find help and information

Janssen Pharmaceutical, a Johnson & Johnson company, manufactures esketamine, and you can visit the manufacturer’s website for more information about the drug. You can also find details on the FDA site. 

NIMH posts links to free brochures you can download for information on specific types of depression. 

If you have an urgent need, connect to the 24/7 confidential Suicide & Crisis Lifeline through the chat function (988lifeline.org) or the phone/text line (988).