Is Ketamine Therapy Covered by Insurance? 2026 Guide

Quick answer

Insurance usually covers Spravato and usually does not cover off-label ketamine. The FDA-approval status of the specific drug is the primary factor.

Spravato (esketamine) is FDA-approved for treatment-resistant depression and covered by most commercial plans and Medicare Part B after prior authorization. Off-label ketamine — IV, IM, and at-home telehealth — is prescribed based on physician judgment rather than FDA labeling, so insurers usually deny it.

What insurance covers Spravato

All five of the top US health plans cover Spravato with prior authorization as of 2026. Coverage of off-label ketamine remains rare across the same plans.

Insurer	Spravato coverage	Off-label ketamine	Prior auth required
Aetna	Yes	No (deemed investigational)	Yes
Blue Cross Blue Shield	Yes (varies by state plan)	Rarely; some state plans	Yes
Cigna	Yes	No	Yes
UnitedHealthcare	Yes	No	Yes
Medicare Part B	Yes (as physician-administered drug)	No	Yes

Most plans require documentation that the patient has tried at least two antidepressants without adequate response before Spravato is authorized.¹

Why off-label ketamine is rarely covered

Off-label ketamine is rarely covered because insurers classify it as investigational for psychiatric use. Ketamine is FDA-approved as an anesthetic but not for depression, PTSD, or chronic pain.²

Some clinics get partial reimbursement by billing the psychiatric evaluation, the office visit, or vital-sign monitoring under standard mental-health codes. The IV infusion itself is usually a self-pay line item.

CPT codes clinics bill

The billing codes matter because you need them for HSA/FSA reimbursement and for any appeal you file.

• 96365 — IV infusion, initial hour (used for the first hour of an infusion visit).
• 96366 — IV infusion, each additional hour.
• J3490 — Unclassified drug (used to bill the ketamine itself for off-label infusions).
• G2082 / G2083 — Spravato administration codes (Medicare and most commercial plans).
• 90792 — Psychiatric diagnostic evaluation with medical services (often the covered piece of an off-label visit).

HSA and FSA eligibility

HSA and FSA funds cover ketamine therapy when a licensed provider prescribes it for a diagnosed condition. The IRS treats it as a qualifying medical expense.

Ask the clinic for a superbill listing the CPT codes above and a letter of medical necessity. Some HSA administrators require both before reimbursement.

How to get prior authorization for Spravato

Prior authorization for Spravato takes 3–14 business days when submitted correctly. Complete the plan-specific Spravato PA form with your prescribing psychiatrist.

1. Confirm you meet the plan's Spravato criteria — usually a treatment-resistant depression diagnosis and at least two failed antidepressant trials.
2. Collect documentation: prior antidepressant trial dates, doses, and outcomes.
3. Submit the plan's Spravato PA form. Include the PHQ-9 or other depression score.
4. If denied, file the plan's appeal — the majority of first-pass Spravato denials are overturned on appeal when documentation is complete.

How to appeal a denial

Denials are usually appealable in writing within 60–180 days. Every plan lists the specific appeal path in its denial letter.

A strong appeal cites the clinical criteria the plan itself publishes, attaches medical-necessity documentation from your prescriber, and includes trial data on Spravato from the Janssen prescribing information.

Cost if you self-pay

Self-pay costs vary sharply by modality. See our ketamine cost guide for the full modality breakdown. At-home telehealth is the least expensive, at $129–$350 per month via providers like Innerwell and Mindbloom.

IV infusion is the most expensive self-pay path — $400–$800 per session, with a typical induction totaling $2,400–$6,000. Intramuscular sits in the middle at $150–$350 per session.

Spravato is the only ketamine-family drug that is usually cheaper with insurance than without. Its list price is $590–$885 per session before coverage.

Medicare and Medicaid

Medicare Part B covers Spravato as a physician-administered drug after prior authorization.³ Traditional Medicare beneficiaries typically owe the 20% coinsurance unless they carry a Medigap plan.

Medicaid coverage of Spravato varies by state. Most state Medicaid plans have added Spravato to their formularies with prior authorization; a small number still deny it. Off-label ketamine is not covered by Medicare or Medicaid.

Federal-plan patients are not eligible for the Janssen withMe copay-support program. Ask your clinic about Janssen's patient assistance program for hardship coverage.

Questions to ask before you book

Ask the clinic five questions before your first Spravato visit. They protect you from surprise bills.

1. Are you REMS-certified for Spravato administration?
2. Do you handle the prior authorization submission?
3. How do you bill: buy-and-bill, or specialty pharmacy?
4. What is my estimated per-visit out-of-pocket after copay support?
5. Do you help me enroll in Janssen's withMe program on day one?

Frequently asked questions