How We Get Spravato Covered by Insurance

"We were told by another clinic that our insurance doesn't cover Spravato." We hear this constantly—and most of the time, we're able to get that same patient approved. Here's how our process works and why we succeed where others struggle.

Our Insurance Success Story

We've helped patients with commercial insurance, marketplace plans, Medicare, Medicaid, and other complex coverage situations get approved for Spravato treatment. Many came to us after being turned away elsewhere.

Why Other Clinics Say "Not Covered"

When a clinic tells you Spravato isn't covered, it usually means one of several things:

1. They Didn't Check Thoroughly

Some clinics do a quick check and give up if it's not immediately obvious. Real verification requires deeper investigation.

2. Prior Authorization Required

"Not covered" often actually means "requires prior authorization." This is extra work that some clinics prefer to avoid.

3. Complex Coverage Situation

Some insurance plans have unusual structures. Navigating them takes expertise and persistence that not every clinic has.

4. They Don't Specialize in Spravato

Clinics that offer Spravato as just one of many services may not have dedicated staff for insurance navigation.

Our Step-by-Step Insurance Process

Here's exactly how we work to get your Spravato treatment covered:

Step 1: Comprehensive Benefits Verification

We don't just call the number on the back of your card. Our team:

Verifies pharmacy benefits (where Spravato is often covered)
Checks medical benefits for the administration/monitoring portion
Identifies specific prior authorization requirements
Determines medical necessity criteria your plan requires
Calculates expected copays and out-of-pocket costs

Step 2: Documentation Preparation

Prior authorization for Spravato requires demonstrating that you meet specific criteria. We help ensure your documentation includes:

Required Documentation

Medical History:

• Diagnosis of major depressive disorder
• History of medication trials
• Documentation of treatment resistance
• Current symptom severity

Treatment History:

• At least 2 failed antidepressant trials
• Adequate dose and duration documented
• Reasons for discontinuation
• Current antidepressant regimen

Step 3: Prior Authorization Submission

We submit the prior authorization request with all supporting documentation. This includes:

Completed authorization forms (often 10+ pages)
Letter of medical necessity from the prescribing provider
Clinical notes supporting the diagnosis
Medication history documentation
Any additional information the specific insurer requires

Step 4: Follow-Up and Advocacy

The submission isn't the end—it's often just the beginning:

We track the request and follow up if decisions are delayed
We respond to information requests quickly with additional documentation
We communicate with medical directors if needed for peer-to-peer reviews
We don't give up after a first denial—appeals often succeed

Step 5: Appeals When Necessary

If an initial request is denied, we don't accept that as final. Our appeals process includes:

Reviewing the denial reason carefully
Gathering additional documentation to address specific concerns
Preparing a formal appeal letter with clinical justification
Requesting peer-to-peer review when appropriate
Escalating through multiple appeal levels if needed

Coverage by Insurance Type

Here's what we typically see with different insurance types:

Commercial Insurance (Employer Plans)

Most commercial plans cover Spravato with prior authorization. Copays vary widely—from $20 to several hundred dollars per session depending on the plan. We work to identify the most cost-effective approach.

Marketplace Plans (ACA)

Coverage varies by plan but is often available. These plans sometimes require more documentation for approval, which is why our thorough process is essential.

Medicare Part D

Medicare Part D typically covers Spravato. The medication is covered under pharmacy benefits, while the administration fee is covered under Part B. We coordinate both components.

Medicaid

Many state Medicaid programs cover Spravato. Georgia Medicaid does provide coverage with proper authorization. We handle the often-complex Medicaid approval process.

Additional Cost-Reduction Options

Even with insurance coverage, we help reduce out-of-pocket costs through:

Manufacturer Savings Programs

Janssen (the maker of Spravato) offers patient assistance programs that can significantly reduce copays for eligible patients. We help identify if you qualify and assist with enrollment.

• Spravato Savings Program: For commercially insured patients
• Janssen CarePath: Additional support options
• Patient Assistance Program: For uninsured or underinsured patients

What If Coverage Is Truly Unavailable?

In rare cases where coverage isn't available, we discuss all options honestly:

Self-pay options: Transparent pricing if you choose to pay out of pocket
Alternative treatments: Other covered options for treatment-resistant depression
Patient assistance: Janssen's programs for uninsured patients
Payment plans: If self-pay is the only option

But in our experience, most patients who are told they don't have coverage actually do—they just need someone willing to do the work to get it approved.

Why We Go the Extra Mile

We understand that treatment-resistant depression is devastating. When you've tried everything and finally found a treatment that could help, being told "your insurance doesn't cover it" feels like another door slamming shut.

We refuse to let insurance complexity be the barrier to effective treatment. That's why we've built expertise in navigating these systems—and why we succeed where others give up.

"The number of patients who come to us after being told no elsewhere—and who we successfully get approved—proves that persistence and expertise matter. We fight for every patient."

Ready to Check Your Coverage?

Don't let what another clinic told you stop you from exploring Spravato. Contact us for a thorough benefits verification. We'll tell you honestly what your coverage looks like—and if there's a path to approval, we'll find it.