How To Get Spravato Approved By Insurance

The first step in navigating insurance for Spravato is understanding who you need to talk to and what information you need to gather. Unfortunately, it’s rarely as simple as calling your insurance company’s main number and asking, “Is Spravato covered?”

Take A Good Look At Your Insurance Card

Navigating the insurance maze starts with the most basic tool in your arsenal: your insurance card. This small piece of plastic—or digital card on your phone—holds critical clues about who you need to contact and where to begin.

Your first step should be taking a clear photo or screenshot of both sides of your card and saving it somewhere easily accessible, in case you lose the card. Trust me, you’ll be glad you did this when you’re on a call and need to quickly reference a number or group ID.

Key Departments to Identify

Look at your card closely. Most insurance cards will list separate phone numbers for different departments:

• Pharmacy Benefits: Spravato is often covered under pharmacy benefits, though this can vary by plan
• Medical Benefits: Sometimes listed separately from pharmacy benefits
• Behavioral Health: Some plans categorize Spravato under mental health coverage
• Member Services: This is your starting point if you’re unsure which department to contact

1. Start with Pharmacy Benefits

Spravato is often covered under pharmacy benefits, not medical benefits. Many insurance representatives default to medical benefits when checking coverage, which can lead to incorrect answers.

What to Say:

• “I’m calling to ask about coverage for Spravato, an FDA-approved ketamine nasal spray for depression. Can you check if it’s covered under my pharmacy benefits?”

If the representative seems unsure or unfamiliar, politely ask:

• “Can you confirm whether Spravato falls under pharmacy benefits, behavioral health, or another category in my plan?”

 

2. Make Sure You Can Explain Spravato Easily

Some representatives may not immediately recognize Spravato by name. Be prepared to explain briefly:

“Spravato is a prescription nasal ketamine for treatment-resistant depression, administered in a certified healthcare setting. It’s not a take-home medication.”

This clarification helps them check the right categories in their system.

3. Don’t Accept the First ‘No’

If the representative says it’s not covered, dig deeper. Politely ask them to double-check:

• “Could you verify that in both the pharmacy benefits and medical benefits sections of my plan?”
• “Can you confirm this decision with a supervisor or another department to ensure accuracy?”

Remember, not every representative is familiar with every treatment, and mistakes happen. A second opinion can make all the difference.

Pro Tip: Ask if they have a dedicated case manager or mental health specialist who can walk you through the process. Some insurers offer this service but don’t advertise it. Also, download your insurer’s mobile app if they have one—it often provides easy access to your digital insurance card and benefit information.

For more pro tips like this, check out my full guide. It’s free…and it will set you free from the bureaucracy!

Insurance jargon can feel like another language, and misunderstanding it can lead to unnecessary delays. Learning the key terms will help you communicate more effectively and avoid confusion.

Key Terms to Know

• Formulary: A list of medications covered by your insurance plan. Spravato may fall under a higher tier, affecting your out-of-pocket costs.
• Step Therapy: A requirement to try other treatments before Spravato. Ask if this applies and how to bypass it. This often ties into fail-first policies, which mandate trying and failing with less expensive treatments first.

You can find a lot more helpful terms helpful to your cause on page 20 of my guide. For now, I want to give you a great example of how knowing a term can help you secure coverage.

Example:
You call your insurer and hear, “Spravato is on Tier 4 of the formulary.” Without knowing what this means, you might assume it’s not covered. In reality, Tier 4 often means higher out-of-pocket costs but not a complete exclusion. By understanding the term, you can ask, “What’s my copay for Tier 4 medications?”

Pro Tip:
If you don’t understand a term, don’t hesitate to ask: “Can you explain what that means in plain language?” Representatives are trained to clarify but may not volunteer explanations unless prompted.

By documenting every interaction and learning key terms, you’ll not only stay organized but also feel more confident navigating the process. These steps build the foundation for successfully obtaining the coverage you need

Inquire About Costs

A few simple questions you can ask:

• “What is my copay or out-of-pocket cost for this treatment?”
• “Will this apply to my deductible or out-of-pocket maximum?”
• “Are there quantity limits per month or authorization period?”
• “Do costs differ between the induction phase and maintenance phase?”

Example:

You might be told, “Spravato is covered, but you’ll need to meet your $2,000 deductible first.” Understanding this upfront helps you avoid unpleasant surprises.

They’re Going To Be Vague About Your Total Costs

There are a lot of moving parts, but you can skip to the section below on costs to understand the no-bs low-down on what you’re going to pay.

Know that it’s not just about how much you’ve paid into your deductible. Other factors that can affect your final bill include:

• Your Out-of-Pocket Maximum – If you’ve already hit it for the year, your remaining treatments might be fully covered. If not, you’ll still be paying a share.
• Your Insurance Plan’s Contracted Rates – Different insurers negotiate different rates with clinics, so the cost per session can vary widely.
• Copay vs. Coinsurance – Some plans have a flat copay per visit, while others require you to pay a percentage of the total cost, which fluctuates.

Click here to see a host of other factors that can impact costs. 

Clarify Pre-Authorization Requirements

• “Does my plan require prior authorization for Spravato?”
• “What documentation does my doctor need to submit?”
• “How long does the authorization process typically take?”
• “If denied, what are the specific denial codes I should know about?”

Dialogue Example:

Insurance Rep: “Yes, we require prior authorization.”
You: “Can you tell me exactly what the pre-authorization process involves and how long it typically takes?”

Get other great questions you can ask, complete with dialogue examples.

Verify In-Network Providers

• “Are there specific treatment centers in-network where I can receive the intranasal ketamine?”
• “What happens if there are no in-network providers in my area?”
• “Will you cover out-of-network providers at in-network rates if no in-network options exist?”

Example:

Let’s say you live in a rural area. Your insurer might allow you to use an out-of-network provider at an in-network rate if no certified treatment centers are nearby.

A Shortcut Once You Confirm Your Insurance Covers Spravato 

• Go to Spravato’s clinic locator and find the nearest Spravato-certified clinic to you. 
• See if the nearest ketamine spray clinics are in your insurance company’s in-network provider list 
• Call the in-network clinic and have THEM figure out how to get prior authorization from your insurer (they’re experts at it and will get it quicker than you can). They’ll also tell you what your out-of-pocket costs are.

Even with preparation and persistence, you might hit roadblocks. When insurance representatives give unclear answers, deny coverage, or leave you in limbo, escalation is your best option. Think of it as climbing the ladder to find someone who has the authority to fix the issue.

Understand the Reason for Denial

Start by asking:

• “Why was my claim denied?”
• “Can you provide the specific policy or guideline used to make this decision?”

My guide has a very detailed process you can follow to successfully appeal the company’s decision. Including getting the ketamine clinic involved as they have a lot of experience in this area.

The first thing to know about Spravato? It’s prohibitively expensive without insurance—and even with coverage, it’s still out of reach for most people. But just how expensive is it? Take a look:

* Based on standard administration protocol of 14 sessions over 12 weeks, with further treatments as needed based on individual response and clinical evaluation.

 

Insurance Typically Covers 50-60% of The Cost

This is why your out-of-pocket costs are so high–even with insurance.

By the way, to make the costs easier to read and compare, I took the midpoint of the price range instead of listing broad estimates. That means the numbers you see aren’t the absolute lowest or highest costs but a middle ground. Some people will pay less than this, while others will pay more. The actual amount depends on factors like location, insurance coverage, and individual clinic pricing.

Now, where do these numbers come from? Insurance tables and ketamine clinic operators. Pricing is almost always given in ranges and usually listed per treatment. But per-treatment costs don’t tell you much if you’re trying to compare different ketamine administration methods. What really matters is the total cost of completing the treatment protocol.

For Spravato, the standard protocol calls for 14 sessions over 12 weeks. In reality, most people go beyond those 14 because maintenance—or booster—sessions are often needed. Some need them monthly, others quarterly, some not at all.

That’s why the numbers you see above are just the baseline—the cost of completing the initial protocol. If you continue treatment, expect to pay more, but how much more depends entirely on your individual response. Read How Many Ketamine Therapy Sessions Will You Need? for more details.

A Flexible Spending Account, or FSA, is a special account offered by employers that lets you set aside money before taxes to pay for certain medical expenses. It’s part of your benefits package and can be a powerful way to save money on healthcare costs. Here’s how it works:

• You decide how much money to contribute to your FSA at the start of your benefits year (up to $3,050 in 2024).
• This money is taken directly from your paycheck before taxes, which lowers your taxable income.
• Throughout the year, you use these funds to pay for eligible medical expenses, like Spravato treatments.

Important Note: FSAs are “use it or lose it” accounts. This means any money you don’t spend by the end of the plan year (or a short grace period) will be forfeited.

Is The Ketamine Nasal Spray Covered by an FSA?

Generally, yes. But I highly suggest you confirm it. There are two ways of doing that and you can see them on pages 53-54 of my guide.

How to Use Your FSA to Pay for Spravato

Two Ways to Access Your FSA Funds

1. Pay Directly with Your FSA Debit Card

If your FSA plan includes a debit card, this is the easiest way to pay for the ketamine spray.

• Step 1: Confirm with your provider’s billing office that they accept FSA cards.
• Step 2: Use your FSA card to pay at the time of service.
• Step 3: Keep your receipt as proof of the transaction.

Important Note: Some FSA cards may flag large expenses for review. If this happens, the administrator may ask for additional documentation to verify the expense.

Example:
After a Spravato session, you swipe your FSA card at the clinic. A week later, your FSA administrator sends you an email: “Please submit proof of medical necessity for this transaction.” Because you kept your prescription and receipt, you’re able to respond quickly and avoid delays.

Check my guide out for the second way to access your FSA funds. It also covers:

• Timeline restrictions, grace periods and rollovers
• Tax benefits of FSAs (with real examples)
• Limitations of FSAs compared to HSAs
• Documentation you’ll need for Spravato
• Common mistakes to avoid
• FAQs