How many Medicaid entities cover esketamine (Spravato)?

75 of 165 entities (45.5%). Among those, 72 of 75 (96%) require prior authorization.

What does a “Not Stated” policy mean for access?

It usually functions like non-coverage unless you pursue case-by-case review or appeal. 90 of 165 entities (54.5%) are Not Stated for esketamine.

Are IV, IM, or oral ketamine covered by Medicaid?

Almost never. IV is covered by 1/165 entities (0.6%), IM by 0, and oral is mostly Not Stated.

Why do people in the same state get different coverage answers?

Because coverage is decided by individual entities inside the state—especially managed care organizations—so plan assignment often determines access.

What should patients and clinics prepare for prior authorization?

Diagnosis notes, treatment history showing failures, clinical rationale for esketamine, and proof the clinic meets REMS monitoring requirements.

Medicaid Ketamine Coverage: 165-Entity Policy Snapshot (2025)

Name: Medicaid Ketamine Coverage (Entities, Routes, and States) — 2022–2024
Creator: Michael Alvear
License: https://creativecommons.org/licenses/by/4.0/

In August–September 2025, 45.5% of Medicaid policy entities cover Spravato with near-universal prior authorization, while IV/IM/oral ketamine are almost entirely unavailable and six jurisdictions have no covering entities at all.

What This Study Found

Across 165 Medicaid decision-making entities in 51 jurisdictions, only 75 (45.5%) provide coverage for esketamine (Spravato), and 72 of those 75 (96%) require prior authorization. A majority—90 of 165 (54.5%)—list Spravato as “Not Stated,” which in practice functions as a barrier requiring case-by-case review. Alternative ketamine routes are effectively shut out: IV is covered by 1 of 165 entities (0.6%), IM by 0, and oral is largely “Not Stated.” Six jurisdictions have zero entities that cover Spravato at all, producing complete access deserts. Because managed care organizations (MCOs) control 100 of 165 decision points (60.6%), policies often conflict within the same state, so a beneficiary’s access can hinge entirely on plan assignment. Net effect: 98.2% of entities require some form of individual review before treatment can proceed, even where nominal coverage exists.

Why It Matters

For patients with treatment-resistant depression or acute suicidal ideation, delays are dangerous. Near-universal prior authorization, “Not Stated” policies, and REMS facility requirements turn paper coverage into a maze of administrative hurdles, shrinking timely access to a therapy designed for rapid relief. Within covered states, inconsistent MCO rules create a lottery effect where two neighbors with the same diagnosis can face opposite outcomes solely due to plan assignment. With IV/IM/oral ketamine virtually excluded, patients who cannot tolerate or access the nasal spray are left without viable Medicaid pathways. The system’s fragmentation wastes clinical time, strains families, and increases the odds of crisis care rather than earlier, scheduled intervention.

Methods in Brief

Cross-sectional review of official, publicly posted Medicaid policy documents (PDF/HTML) from state agencies, MCOs, and PBM carve-outs covering all 51 jurisdictions. Route-specific determinations (Spravato, IV, IM, oral) were coded per entity from controlling sources (clinical/medical policies, PDLs, prior-auth criteria, drug lists, billing manuals). Entity selection was enrollment-weighted; CMS Medical Loss Ratio Public Use File (Reporting Year 2023) informed plan presence cross-checks. Data capture and verification occurred primarily in August–September 2025; quotes were limited to ≤25 words and URLs/page cites were logged for audit. Policy silence was recorded as “Not Stated.” Policies were not inferred from third-party summaries.

Limitations & How to Interpret

Findings reflect posted policies at the time of verification; internal criteria and fast-changing portals can create gaps or dead links. Policies were sampled at the entity level; state riders and local carve-outs may vary. “Not Stated” indicates no posted determination, which typically functions as non-coverage but can yield case-by-case exceptions. Enrollment share estimates were conservative; where unclear, values were left “Not Stated” rather than imputed.

Data & Materials

White paper (Zenodo record): https://zenodo.org/records/17113412

Zenodo dataset DOIs: 10.5281/zenodo.17041139; 10.5281/zenodo.17041210; 10.5281/zenodo.17041502

Wikidata item: https://www.wikidata.org/wiki/Q136285557

License: Creative Commons Attribution 4.0 International

Last verified date: September 14, 2025

Dataset download: https://ketaminetherapyfordepression.org/datasets/medicaid-ketamine-coverage-policies/

More analysis: https://ketaminetherapyfordepression.org/does-medicaid-cover-spravato/

How to Cite

Alvear, M. (2025, Aug 31). Medicaid Coverage of Esketamine and Ketamine Therapies: Cross-Sectional Policy Analysis Across 51 Jurisdictions and 165 Coverage Entities. Zenodo. DOI: 10.5281/zenodo.17113412

FAQ

Is Spravato covered by Medicaid in my state?

Often, but not reliably. In 45 of 51 jurisdictions at least one entity covers Spravato, yet at the entity level only 45.5% provide coverage. That means your access depends on which plan you’re on, not just your state. In practice, most plans require prior authorization and REMS-certified clinics, which can create delays and travel burdens. If your entity lists Spravato as “Not Stated,” it usually defaults to case-by-case review rather than a clear yes. That means checking both your state Medicaid site and your plan’s medical policy is essential before you schedule care.

Why do plans require prior authorization for Spravato?

Spravato is a high-cost, specialty treatment with strict safety monitoring. Plans use prior authorization to confirm diagnosis (typically treatment-resistant depression), document prior medication trials, and ensure REMS compliance at the clinic site. It’s meant to manage cost and safety, but it slows access for people in crisis. In practice, that usually looks like your prescriber completing forms, attaching chart notes, and scheduling treatment only after approval, which can add days to weeks depending on the plan’s throughput.

What about IV, IM, or oral ketamine—are those covered?

Nearly never. Among 165 entities, only one covers IV ketamine, none cover IM, and oral is largely “Not Stated.” Plans typically label these routes investigational or avoid explicit positions. That means Medicaid beneficiaries who can’t use the nasal spray have almost no formal pathways. In practice, that usually looks like denials at the authorization stage and very rare case-by-case exceptions when there’s compelling clinical justification and a willing provider network.

Why does plan assignment matter so much?

MCOs control 60.6% of the decision points, and they don’t always follow the state’s baseline policy. Two plans in the same state can treat identical patients differently—one covers, another stays silent. That means the same diagnosis can face different rules, forms, and timelines just based on which plastic card is in your wallet. In practice, that usually looks like calling your plan’s member services and asking specifically for the Spravato medical policy and prior authorization criteria before committing to a treatment plan.

How can I speed up approval if I’m in crisis?

Ask your prescriber to submit a complete prior authorization packet the first time: diagnosis, medication failures and augmentations, PHQ-9 scores, psychiatrist attestation, REMS clinic enrollment, and the clinic’s monitoring protocol. Some plans allow expedited reviews for safety concerns. That means you and your clinician should request an urgent review and be ready to answer plan callbacks within 24–48 hours to prevent the request from timing out.

Author & Contact

Author: Michael Alvear

Contact: [email protected]

ORCID: https://orcid.org/0009-0003-3845-418X

Last reviewed: September 14, 2025