How Medicare Covers SPRAVATO® — and What to Ask Your Plan

Why coverage usually follows the treatment setting SPRAVATO® (esketamine) nasal spray is never dispensed for home use. Patients self-administer it under direct supervision in a healthcare setting certified under the REMS program, then stay for monitoring of at least two hours after each dose. Because the medicine is given in a clinic setting, coverage for SPRAVATO® is typically handled under Medicare Part B (outpatient medical services) rather than the Part D pharmacy benefit — but the details depend on your plan.

What original Medicare typically involves With original Medicare (Parts A and B), after you meet the annual Part B deductible you generally pay 20% of the Medicare-approved amount and Medicare pays the rest. A Medigap policy may cover some or all of that share. The clinic's own administration or observation fees may be billed separately, so it is worth asking what appears on each visit's claim.

What varies by plan - Medicare Advantage plans can use networks, referrals, and prior authorization — check whether your clinic is in network. - Some plans ask for documentation before approving treatment, such as prior antidepressant trials or depression severity scores. - Medicaid rules differ by state, including for adults who qualify on both Medicare and Medicaid.

Questions to ask before your first visit 1. Does my plan cover SPRAVATO® under Part B (or my Medicare Advantage plan's medical benefit)? 2. Is prior authorization required, and what documentation does it need? 3. What will I pay per visit — deductible, coinsurance, or both? 4. Does the clinic bill the observation or monitoring visit separately? 5. If I have Medigap or Medicaid, how do they combine with my Medicare coverage?

General information, not medical advice. Coverage depends on your specific plan. Source: Medicare.gov coverage rules.