Insurance Coverage for TMS and Spravato

For many patients with treatment-resistant depression (TRD), therapies like Transcranial Magnetic Stimulation (TMS) and Spravato (Esketamine) provide a crucial lifeline. However, securing insurance coverage for these treatments can be challenging due to varying policies, requirements, and approval processes.

This comprehensive guide will break down everything you need to know, including whether TMS and Spravato are typically covered by insurance, the available financial assistance options, out-of-pocket costs, and which insurance plans may not cover these therapies. With this information, you’ll be equipped to help your patients access these important treatments without unnecessary delays or financial hurdles.

Is TMS Covered By Insurance?

Transcranial Magnetic Stimulation (TMS) is an FDA-approved therapy for patients with major depressive disorder (MDD) who have not responded to traditional antidepressant treatments.

It’s important to note that coverage can vary based on several factors, including the patient’s diagnosis, treatment history, and insurance plan.

To be eligible for coverage, patients usually need to meet specific criteria:

• Diagnosis of Treatment-Resistant Depression (TRD): Most insurers will only cover TMS if the patient has been diagnosed with major depressive disorder and has not responded to at least two different antidepressant medications.
• Failed Previous Treatments: Insurers often require proof that patients have failed to respond to at least two different classes of antidepressant medications before considering TMS.
• Medical Necessity: The insurer will need to see that TMS is medically necessary. Healthcare providers should submit clear documentation to demonstrate the patient’s treatment history and how TMS is the appropriate next step.

Pre-Authorization Process

Before starting TMS treatment, many insurance providers require prior authorization. This means that you must submit detailed documentation to the insurance company to prove that the patient meets the necessary criteria for TMS. Getting prior authorization can be a time-consuming process, but it is crucial to ensure that the insurance provider will cover the treatment.

A notable exception is that, effective March 6, 2026, Evernorth Behavioral Health (part of The Cigna Group) has removed the prior authorization requirement for Transcranial Magnetic Stimulation (TMS) when contracted/in-network providers provide services for patients with coverage under Evernorth and Cigna Healthcare plans. Services with dates before March 6, 2026, may still require authorization. Non-contracted/out-of-network providers must continue to obtain prior authorization.

For more details you can read our article:
Pre-authorization in TMS Billing

Exceptions and Limitations

While most major insurance providers cover TMS, there are exceptions:

• Some high-deductible plans or small commercial insurance providers may not offer coverage for TMS.
• State Medicaid programs may not cover TMS or may have very specific requirements that vary by state.
• Some insurance companies might require patients to undergo a mental health evaluation before they approve TMS treatment.

Is Esketamine (Spravato) Covered By Insurance?

Spravato, or Esketamine, is another FDA-approved treatment for patients with treatment-resistant depression. This nasal spray works by targeting specific receptors in the brain to rapidly reduce depression symptoms. Like TMS, Spravato is generally covered by insurance, but the coverage requirements can vary.

But there are specific requirements that patients need to meet:

• Diagnosis of Treatment-Resistant Depression: Spravato is typically covered only for patients who have been diagnosed with treatment-resistant depression, which means they haven’t responded to at least two different antidepressant medications.
• Treatment Setting: Unlike TMS, Spravato must be administered in a certified treatment center under medical supervision. This requirement may impact insurance coverage, as some insurers will only cover Spravato if it’s administered in an approved facility.
• Pre-Authorization: Like TMS, Spravato requires prior authorization. The healthcare provider must submit a detailed medical history and treatment plan, as well as documentation of previous failed treatments.

Pre-Authorization Process

For Spravato, the pre-authorization process typically involves submitting:

• A diagnosis of treatment-resistant depression
• Evidence of failure from at least two antidepressant medications
• A treatment plan outlining the proposed course of Spravato therapy
• Confirmation that the patient will receive Spravato in an FDA-approved treatment center

Spravato withMe Savings Program

One of the biggest challenges patients face when it comes to Spravato is the cost. Without insurance, Spravato can cost around $8,200 (lower dose of 56 Mg) for the first month of treatment, which includes the medication and the administration fee may vary at the certified treatment facility.

Fortunately, there are financial assistance programs available to help offset the cost for eligible patients.

The Spravato withMe Savings Program helps make Spravato (Esketamine) more affordable for eligible patients. Here’s a quick overview of the key financial assistance options:

• Commercially Insured Patients: Eligible patients with commercial insurance can pay as little as $10 per session for Spravato medication, with an annual savings of up to $8,150 and it does not include observation fees during treatment sessions.
• Rebate Options: If a provider or pharmacy doesn’t accept the savings card, your patients can pay out-of-pocket and submit a rebate request for reimbursement.
• Observation Rebate: Your patients can qualify for up to $500 in rebates annually to cover observation fees during treatment sessions.
• Care Navigator Support: Enrolled patients receive support from a Care Navigator, who helps with cost management, insurance navigation, and finding additional resources.
• Eligibility Requirements: The program is available to patients aged 18+ with commercial or private insurance. Medicare and Medicaid recipients are excluded, and there’s no income requirement to apply.
• Additional Assistance: Uninsured or underinsured patients may receive help from Janssen CarePath to connect with state programs or foundations that assist with prescription costs.

The Spravato withMe Savings Program can help your patient to reduce their financial burden. This assistance can cover a large portion of the medication cost, making it more affordable for patients.

Out-of-Pocket Costs for TMS and Spravato

While both TMS and Spravato are often covered by insurance, out-of-pocket costs can still be a significant concern for patients. Understanding these costs is critical so you can help your patients plan for the financial aspects of their treatment.

TMS Out-of-Pocket Costs

TMS is generally covered by insurance, but many patients still face out-of-pocket expenses. The total cost of TMS therapy can range from $6,000 to $15,000 for a full course of treatment (usually 30 to 36 sessions). Even with insurance, patients may still be responsible for:

• PR-1: Deductibles
• PR-2: Co-insurance
• PR-3: Co-pays

If your patient has a high-deductible health plan, they may be required to pay a significant portion of the total treatment cost. This can be a financial burden, especially if they need ongoing TMS sessions.

Spravato Out-of-Pocket Costs

The cost of Spravato can be much higher than TMS, especially for patients who don’t have insurance coverage. The first month of treatment for Spravato can cost around $8,200 (lower dose of 56 Mg) for medication and the cost of administration at a certified treatment center may vary. After the first month, the cost may decrease, but it is still a significant financial commitment.

Even with insurance, patients may still face high co-pays, particularly if their insurance plan has high out-of-pocket limits. Again, financial assistance programs can help reduce this burden.

Which Insurance Plans Don’t Cover TMS and Spravato?

While many insurance providers cover TMS and Spravato, some may not, or may have very specific requirements.

Insurance Plans That Don’t Cover TMS

• Medicaid: Some state Medicaid programs may not cover TMS or may only cover it under very specific circumstances. Coverage varies by state, so it’s important to check with the local Medicaid office to confirm.
• High-Deductible Health Plans: Many high-deductible plans may not cover TMS or may have limited coverage, leaving patients to pay the bulk of the cost out of pocket.
• Non-Standard Commercial Insurers: Some smaller insurance companies or limited coverage plans may exclude TMS from their mental health benefits.

Insurance Plans That Don’t Cover Spravato

• Medicare Advantage Plans: While Medicare Part B generally covers Spravato, some Medicare Advantage plans may not or may have restrictions on where Spravato can be administered.
• PPO and HMO Plans: Depending on the specific plan provider, certain PPO or HMO plans may exclude Spravato coverage or limit the number of treatments covered annually.

Conclusion

Navigating insurance coverage for TMS and Spravato can be complicated, but understanding the key requirements and working closely with insurers can make the process smoother for both you and your patients. By helping your patients understand the insurance coverage, financial assistance programs, and potential out-of-pocket costs, you can ensure they receive the care they need.