Depression affects an estimated 29% of all U.S adults, and one-third of those affected won’t respond to standard treatment. Spravato (esketamine) is a promising novel antidepressant that has emerged in recent years.
If you’re wanting to use Spravato, but are worried about the costs, you may be eligible for coverage from Medicaid. This article will discuss the criteria and process for getting Spravato covered by health insurance.
Key Takeaways
- Spravato (esketamine) was approved by the FDA for treating treatment-resistant depression and major depressive disorder with suicidal ideation.
- Medicaid coverage for Spravato can vary depending on the state and individual’s eligibility criteria.
- Factors like the severity of the depression, previous treatments, and medical necessity play a role in Medicaid’s decision to cover Spravato.
- Patients may need to go through a prior authorization process and provide supporting documentation to obtain Medicaid coverage for Spravato.
- Understanding the specific Medicaid coverage policies in one’s state is crucial for accessing this potentially life-changing treatment.
Introduction: Understanding Spravato and Its Uses
What is Spravato and How Does It Work?
Ketamine is what’s known as a racemic mixture, meaning it contains an equal amount of two mirror image molecules called enantiomers. Ketamine’s enantiomers have long interested researchers, with studies indicating they have less psychoactive side effects compared to ketamine’s racemic mix.
In 2018, multiple studies from Janssen Pharmaceuticals found esketamine could have rapid and significant antidepressant effects in those with treatment-resistant cases. This included trials with Spravato, a nasal spray version of the drug, which the pharmaceutical company had earlier developed.
The evidence prompted the FDA to approve Spravato as a medication for certain types of depression in 2019, and over 30,000 patients have since received the treatment.
Esketamine works differently to conventional antidepressant medications, such as SSRIs. Through blocking NMDA receptors in the brain, esketamine increases the action of a chemical called glutamate. In turn, this increases the process of neuroplasticity, believed to help patients with depression “rewire” unhealthy thought and behavior patterns.
SSRIs, on the other hand, increase the levels of serotonin, a mood-regulating chemical, by preventing its reabsorption into brain cells. This higher serotonin level gradually improves mood but usually takes a few weeks to feel the full effect. In contrast, esketamine can produce rapid onset antidepressant effects, and doesn’t require as many doses.
Does Medicaid Cover Spravato?
Medicaid is a state and federal government program that gives free or low-cost health coverage to those with limited income and resources. Medicaid can help individuals in need cover the cost of Spravato. However, this process requires patients to meet specific criteria.
Medicaid Coverage Criteria for Spravato
For applicants TRP, individual must show an inadequate response to the maximum tolerated dose of two antidepressant therapies during a major depressive episode. This is defined by a less than 50% reduction in severity symptoms, measured using a validated scale.
For applicants with MDD and suicidality, individuals must show a high risk for suicide based on the judgement of their clinician.
Patients must go through a detailed check-up to see if they can use it. The way the medicine is given is also closely watched to make sure it’s safe and works well.
Navigating the Approval Process for Spravato
Getting Medicaid to cover Spravato (esketamine) is complex, but knowing what documents and evaluations you need can help. This makes it easier for patients and their doctors to get through the approval process.
Required Documentation and Evaluations
To get Medicaid to cover Spravato, you and your doctor need to show it’s medically necessary. You’ll need to provide documents like your diagnosis, treatment history, and current depression status. Also, a psychiatrist must prescribe Spravato in a certified center.
Relevant documents may include:
- Detailed medical records, including previous treatment attempts and response
- A comprehensive psychiatric evaluation by a licensed mental health professional
- Evidence of treatment resistance or severe, treatment-resistant depression
- Proof of the patient’s eligibility for Medicaid coverage
The process for getting Spravato approved can be tough, but with the right documents and a detailed evaluation, you can boost your chances. This makes it easier to get Medicaid to cover this new treatment.
Potential Out-of-Pocket Costs for Spravato
Medicaid covers Spravato for eligible patients, but there might still be some costs. The cost can change based on the patient’s Medicaid plan and coverage details.
Spravato is covered by Medicare Part B, which pays 80% of expenses. This includes the price of the medication and the cost of the doctor’s visit associated with the administration of Spravato. Patients will need to pay the additional 20%.
To understand the Spravato out-of-pocket costs, patients should look at their Medicaid coverage. They should talk to their healthcare provider too. This way, they’ll know about any costs they might have when getting this treatment.
The Medicaid coverage for Spravato can differ by state. Some states offer more coverage than others. So, patients should check their Medicaid plan’s details.
Knowing about the potential costs helps patients make better choices about their treatment. It ensures they get the care they need without unexpected money problems.
State-Specific Variations in Medicaid Coverage
Medicaid coverage for Spravato is available across the U.S. But, the process and details can change a lot by state. Patients looking for Spravato through Medicaid should know these differences to get through the system well.
Some states might ask for more than the usual Medicaid stuff for Spravato. This could mean extra papers, needing a doctor’s okay first, or limits on how many treatments you can get.
To get the best results, patients should talk to their state’s Medicaid about Spravato. This helps them get ready with the right papers and meet any extra rules. It makes getting approved easier.
Conclusion
Medicaid covers Spravato (esketamine) for those with MDD and TRD. However, the approval and coverage details may change based on the patient’s condition and their state’s Medicaid. Patients can get this new treatment by understanding the criteria and the approval steps.
Medicaid’s coverage of Spravato is a big step in helping people with hard-to-treat depression and suicidal thoughts. By knowing who can get it and how to get it, patients can better navigate their healthcare. This could lead to better treatment and quality of life for many.
FAQs
What are the Criteria for Medicaid Coverage of Spravato?
To get Medicaid coverage for Spravato, patients must be 18 or older and have a documented diagnosis of moderate to severe depression. They also need to use Spravato with an oral antidepressant. If you search “Medicaid Spravato requirements,” followed by the name of your state on your search engine, you should find a document with a more comprehensive eligibility criteria list, that is specific to your area.
What are the Benefits of Taking Spravato (Esketamine)?
Spravato can help relieve depression symptoms when standard antidepressants don’t work. The effects have a more rapid onset and tend to last longer than conventional antidepressant medication.
What is the Approval Process for Spravato Under Medicaid?
To get Medicaid coverage for Spravato, patients and their doctors must go through an approval process. They need to provide documents about the patient’s diagnosis, treatment history, and current depression status.
Are There State-Specific Variations in Medicaid Coverage of Spravato?
Yes, Medicaid coverage and approval for Spravato can differ by state. Some states might have extra requirements or restrictions not found in the general Medicaid criteria.
Source Links
- https://www.medicare.org/articles/does-medicare-cover-esketamine/
- https://www.wyhealth.net/does-medicaid-cover-spravato/
- https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=59250&keyword=spravato&areaId=all&docType=NCA,CAL,NCD,MEDCAC,TA,MCD,6,3,5,1,F,P&contractOption=all&sortBy=relevance&bc=1