Does Medicare Cover Spravato?
Millions of people in the United States, young and old, live with some degree of depression. Because more focus is put on the symptoms that young people experience, not everyone recognizes depression in older adults.
It’s important to be aware of some common symptoms of depression in seniors (like those listed below), whether you’re caring for someone or worried about yourself:
- Feelings of emptiness or lifelessness
- Feelings of hopelessness, guilt, or helplessness
- Moodiness, irritability, increased anxiety
- Loss of energy, fatigue
- Slower movements or speaking
- Sleeping problems
- Difficulty concentrating, memory loss, indecisiveness
- A change in eating habits
- Thoughts of suicide or self-harm
If you recognize any of the symptoms mentioned above, you should see your primary care physician who might prescribe Spravato as a treatment option.
Spravato, an N-methyl-D-aspartate receptor blocker, is a prescription medication containing esketamine and is used to treat treatment-resistant depression (TRD) or major depressive disorder (MDD). It’s administered as a nasal spray, usually together with at least one other oral antidepressant medication. Because of the risk of addiction, Spravato should be taken under the supervision of a medical professional at a certified medical facility.
Does Medicare cover Spravato prescriptions?
Even though you need medical supervision while taking Spravato, it isn’t covered by Medicare Part B (medical insurance). To get coverage for Spravato intranasal spray as a treatment for MDD or TRD, you need Medicare Part D prescription drug coverage.
If you’re eligible for enrollment in Medicare insurance, you’re also eligible to enroll in prescription drug coverage. If your Medicare coverage is through Original Medicare Part A and/or Part B, you can purchase a stand-alone Prescription Drug (Part D) Plan from a Medicare-affiliated private insurance provider.
If you decide to enroll in a Medicare Advantage (MA) plan as an alternative to Original Medicare Parts A and B, and you wish to have prescription drug coverage too, you should find an MA plan that includes additional coverage for prescription drugs, an MA-PD plan.
All Medicare Prescription Drug Plans and MA-PDs are provided by private insurers required to include at least two types of drugs used commonly by Medicare recipients in each category. However, they may have options in what drugs they include on their formularies (list of covered drugs).
It’s possible that Spravato isn’t included on every Part D formulary, so you should check all plans available in your service area to find one that does before enrolling.
How much does a prescription of Spravato cost with and without Medicare coverage?
If your Part D plan lists Spravato on its formulary, your out-of-pocket costs depend on what your plan has set for copayments or coinsurance, the amounts you pay after meeting your deductible.
If your plan charges copayments, the amount depends on the tier level assigned to your prescription drug:
- Tier one drugs are generic low-cost drugs with the lowest cost-sharing amount.
- Tier two drugs are non-preferred generic drugs with a medium cost-sharing amount.
- Tier three drugs are preferred brand name drugs with a high copayment.
- Tier four drugs are non-preferred brand-name drugs with the highest cost-sharing amount.
- Tier five drugs are the specialty drugs like injectables, rare, and more expensive drugs. You pay a fixed percentage (usually 25%) of the market cost of the drug rather than a set copayment amount.
If you don’t have Medicare insurance coverage for Spravato, your final cost will depend on where you live and where you purchase it. The national average cost for 28 mg of Spravato nasal spray is approximately $780 for a two-spray supply. Many U.S. pharmacies accept drug discount cards to help you lower your out-of-pocket costs.