Accessing Care: Insurance for Spravato Treatment, Costs of Ketamine Therapy, and TMS Logistics
When you’re ready to seek care, the details matter. Patients often ask why Spravato treatment is covered while off‑label ketamine therapy isn’t, how TMS fits with insurance, and what to confirm with a clinic before starting.
This guide keeps the focus practical so you can plan a path that fits what’s possible for your life.
Why Spravato treatment is often covered and off‑label ketamine often isn’t
Spravato (esketamine) is FDA‑approved for treatment‑resistant depression and must be given in a certified Spravato center like Lumin Health with on‑site monitoring. Because esketamine (Spravato) is approved for specific indications — treatment-resistant major depressive disorder (MDD) and MDD with suicidal thoughts — and route — intranasal — many health plans include it as a covered benefit when criteria are met. Insurers often ask for:
- A diagnosis of treatment‑resistant major depressive disorder
- Documented trials of antidepressants and augmenting agents at adequate dose and duration
- Sometimes a course of psychotherapy or documentation about why psychotherapy is not feasible right now
Delivered as intramuscular injections at Lumin Health, off-label ketamine is not FDA‑approved for depression, but is still considered safe and evidence-based for depression, anxiety, PTSD, and more. Many plans treat it as an uncovered service or apply out‑of‑network benefits. Some patients still pursue off‑label ketamine treatment when they value flexibility in dosing, when insurance coverage is not possible, or when local access is better than for Spravato. Costs vary by provider, region, and treatment schedule. When comparing options, include time as a cost: travel, observation, and recovery.
A balanced way to view coverage:
- Spravato treatment is more likely to be covered because of FDA approval and REMS rules.
- Off‑label ketamine therapy can be clinically appropriate for some people but has less predictable insurance support.
Both are safe and effective routes of receiving ketamine for depression. The choice often comes down to access, cost, and preference for structure.
TMS coverage patterns and maintenance considerations
Transcranial Magnetic Stimulation (TMS) is covered by many insurers for treatment‑resistant depression when criteria are met. Plans commonly require:
- Prior trials of antidepressants (and sometimes psychotherapy)
- A structured acute course, often five sessions per week for 6–9 weeks
- Symptom tracking during treatment
Most patients can drive to and from visits because TMS does not impact consciousness. It’s important to note too that some plans authorize booster sessions or a second acute course if symptoms return, but is dependent on your specific situation. Ask your TMS provider how they document progress and when they reassess.
Clinical requirements for Spravato (REMS, monitoring)
Spravato administration is available only through a Risk Evaluation and Mitigation Strategy (REMS) program. Practical implications for you:
- Spravato treatment is administered at a certified Spravato administration site.
- Registered clinicians monitor your vital signs before, during and after dosing.
- You remain under observation, typically about two hours per visit.
- Because transient perceptual changes are common, you’ll need a ride home and should not drive until the next day.
- The dosing plan often starts twice weekly for four weeks, then weekly for four weeks, then weekly or every other week thereafter. Some people can space treatments out even further or only come on an as needed basis.
These steps are in place to ensure a laser focus on safety is present. Many patients appreciate the structure and on‑site team, especially early on. Lumin Health’s dedicated team of academically-affiliated psychiatrists and diverse mental health experts is hand-selected to ensure utmost attention to safety and comfort.
What to ask your a ketamine/esketamine medical practice before starting ketamine therapy or esketamine (Spravato)
Use this checklist to reduce surprises. Copy it into a message or bring it to your call.
Spravato and Ketamine Therapy Coverage & costs
- Is Spravato treatment covered for my diagnosis? What criteria must be met?
- What will my copay or coinsurance be per Spravato or ketamine visit?
- Is there a separate facility fee?
Esketamine and Ketamine Treatment Program structure
- For Spravato: how do you monitor efficacy and adjust the plan?
- For off‑label ketamine treatment: what route is used (IV or IM), what’s the typical cadence, and how long is observation?
- For TMS: how many sessions are authorized and what does a maintenance plan look like if I respond?
Logistics for Ketamine and Esketamine (Spravato)
- Can the clinic provide work or school letters explaining time away and the no‑driving rule?
- Who do I call after hours if I feel unwell following a dose?
Coordinating Ketamine or Spravato Treatment
- Do you coordinate with my outside providers?
- How will medications I already take be handled during ketamine therapy?
Bring a support person to help track answers. You are allowed to ask for plain language and written estimates.
FAQs
Can I switch from off‑label ketamine to Spravato later?
Making that switch is possible. Patients sometimes start with off‑label ketamine treatment and switch to Spravato treatment for coverage or scheduling reasons. The Lumin Health team will review your history, current response, and timing to set a safe plan that’s designed for your efficacy in mind. You’ll receive Spravato only in a certified Spravato clinic with observation.
Do I need a psychiatrist to prescribe ketamine?
You’ll need a prescribing clinician and a program that provides monitoring, which is constantly present at Lumin Health. For esketamine (Spravato) treatment, a certified Spravato administration site and REMS enrollment are required. Off‑label ketamine therapy is delivered in-person by trained medical teams with protocols for screening and follow‑up. If you already work with a psychiatrist and/or primary‑care clinician, Lumin Health would be glad to coordinate care with your permission. Many insurances require that a mental health prescriber be involved in the decision to move forward with, specifically, esketamine.
Is off‑label ketamine the same as Spravato?
They are related but not the same. Spravato is chemically known as “esketamine” and has FDA approval for treatment‑resistant depression and a defined in‑clinic program. It is actually an active component of ketamine. Off‑label ketamine is administered through intramuscular dosing at Lumin Health.
Can I use HSA/FSA funds for off-label ketamine care?
Many patients are able to use these accounts. Ask your plan how to document sessions and whether a superbill is required.
A practical way to move forward with ketamine therapy or esketamine (Spravato)
Access to safe and effective ketamine care is not only about insurance coverage, though it is a crucial piece of the puzzle. It is also about commitments, logistics, and support at home. If Spravato treatment can be covered by insurance plans and the cadence works for you, starting with a Spravato treatment plan can offer structure and safety. If you are comparing off‑label ketamine therapy, do not hesitate to ask for a transparent fee schedule and confirm monitoring. If TMS fits better because you prefer to stay fully alert and can attend weekday visits, that is a sound choice too.
Whichever path you choose for ketamine therapy, Lumin Health can help you match coverage, logistics, and comfort to a plan you can keep. Lumin Health provides ketamine for depression with careful monitoring, including Spravato treatment in our certified Spravato clinic, and collaborates with TMS partners when that route fits you best.
