Medicaid coverage for Spravato, ketamine and TMS: state by state overview

How Medicaid decides

Each state runs its own program. Most enrollees are in managed care plans (Molina, Centene affiliates, UnitedHealthcare Community Plan, Anthem, and regional plans) that must follow the state's preferred drug list and prior authorization rules, sometimes adding their own. See the coverage hub, the Spravato hub, the coverage checker, treatment comparisons and condition and treatment pages.

Spravato

Because Spravato is a drug covered under the federal rebate program, states must cover it in some form. In practice every state lists it with prior authorization that mirrors the FDA label: major depressive disorder, two failed antidepressants, an oral antidepressant during treatment, and treatment at a certified center enrolled with Medicaid. Copays are /bin/bash to per visit and many enrollees are exempt.

The practical barrier is provider enrollment: a certified Spravato center must also be enrolled with your state's Medicaid or your managed care plan. Our clinic pages show which clinics list Medicaid.

TMS

Coverage varies more. Most states cover TMS for adults with treatment-resistant depression with prior authorization; a few limit it to specific plans or require additional failed trials. Managed care plans frequently apply commercial-style criteria (two to four antidepressant failures and a psychotherapy trial).

Ketamine infusions and KAP

Off-label ketamine is not covered by any state program we have reviewed. Psychotherapy visits that are part of KAP may be covered as standard therapy when the clinician is a Medicaid provider.

Reading your state's page

Each state Medicaid page on the coverage hub shows the status we have reviewed, the criteria, and clinics in the state that list Medicaid. Where we have not yet reviewed a state's written policy, the page says so and shows the criteria most states use. The pipeline re-reads policy documents monthly, and a clinician re-approves each summary after a change.

Dual eligibility

If you have both Medicare and Medicaid, Spravato and TMS bill Medicare first and Medicaid covers the coinsurance. See Medicare and Spravato.