An Easy Guide to Insurance Coverage for Ketamine Treatment

Learn about the latest developments and get practical tips for navigating health insurance for ketamine therapy.

An Easy Guide to Insurance Coverage for Ketamine Treatment

Despite the growing evidence demonstrating ketamine to be a powerful new treatment option for mental health conditions like anxiety and depression, insurance coverage for ketamine therapy remains inconsistent and limited.

Navigating the process of getting your treatment covered can be confusing and frustrating, but we’re here to help. Keep reading to find out more about the current insurance landscape and learn more about what your options are.

The Current State of Insurance Coverage for Ketamine Treatment

Ketamine has been approved by the FDA since 1970 as an anesthetic, but its use for psychiatric conditions is considered "off-label." 

Despite the prevalence of off-label prescribing within healthcare (in the US, about 1 in 5 prescriptions are written for an off-label use), many insurance providers classify ketamine as “experimental” and choose not to cover the costs of treatment.

Spravato, an intranasal form of esketamine (a ketamine derivative) that received FDA approval specifically for treatment-resistant depression in 2019, has seen more success in securing coverage than the generic ketamine used in IV and IM infusions, and in oral dosing with tablets or lozenges. Today, most major insurance companies offer reimbursement for Spravato treatment - however, not every patient is eligible for or best suited to this form of treatment.

The breadth of insurance coverage for IV, IM, and sublingual/oral ketamine has seen gradual progress over the last several years.

Initiatives like the Mental Health Parity Act aim to ensure equal access to mental health services, including innovative treatments like ketamine. 

The introduction of new AMA CPT 3 codes for psychedelic therapies by the American Medical Association marks another promising milestone on the path to wider coverage. 

Organizations like The Ketamine Task Force are actively working to advance the cause by lobbying for policy changes and increasing awareness about the clinical benefits of ketamine therapy. Their work is crucial in paving the way for making ketamine therapy accessible and affordable.

Together, these developments paint a promising picture for the future - showing a gradual shift in the right direction for broader accessibility.

Current Coverage Options 

The landscape is slowly evolving, with some insurers beginning to offer partial coverage on a case-by-case basis. Certain providers and programs, such as Enthea, are pioneering the space by offering coverage plans specifically for psychedelic-assisted therapies, including ketamine, as part of health benefits packages. This is a promising development for broader acceptance and insurance support for ketamine treatments in employer benefits programs.

Institutions like the Veterans Affairs (VA) have also begun to recognize the value of ketamine therapy, providing coverage for qualifying conditions such as severe depression and PTSD for their specific patient populations. This highlights a significant shift towards making these treatments more accessible, particularly for vulnerable populations such as Veterans. 

Even if you’re unable to get the full cost of your treatment covered, there are options available that can help to offset the cost. For example, insurance may cover related services like consultations, psychiatric evaluations, or follow-up visits. To request this partial refund, patients can submit a form known as a superbill to their insurance provider. A superbill is an itemized receipt that breaks down the medical services you received into separate charges. Many patients successfully receive at least partial refunds for the cost of their treatment by submitting a superbill to their insurer. Talk with your care provider to see if they can provide you with the proper paperwork for superbill submission.

How Wondermed Can Help

At Wondermed, we’re committed to making innovative therapies, like our at-home ketamine treatment program, accessible and affordable to all patients who would benefit. 

Internal and Partnered Providers

If your clinician is part of Wondermed’s internal provider network, we make it easy for you to request partial reimbursement from your insurer by providing you with completed superbills upon request. Currently, Wondermed uses two specific superbill codes to help you get refunded for both your initial psychiatric evaluations, as well as follow-up consultations.

For patients accessing treatments through our partnered providers, insurance coverage for clinical consultations may be available based on the provider's coverage plans. Check with your clinical provider, accessible through your Wondermed dashboard, regarding their specific coverage plan.

Future Partnership with Enthea

The industry has seen a rise of interest from employers to add psychedelics as a covered benefit for their employees. Wondermed has been working with companies such as Enthea, a third party benefits administrator focused on ketamine, to increase access to our protocol.

Employees covered under Enthea's plan will be eligible for 100% coverage of costs associated with Wondermed’s ketamine treatment program.

If your employer is not currently partnered with Enthea, consider initiating a conversation with your company's benefits team. Discussing the potential inclusion of Enthea in your company's insurance coverage plan could open new avenues for mental health treatment options at minimal costs.

Utilizing HSA/FSA Payment Cards

Another flexible option for managing the costs associated with ketamine therapy at Wondermed is by using an Health Savings Account (HSA) or a Flexible Spending Account (FSA). 

Wondermed accepts HSA and FSA cards as a form of payment, providing a convenient way to use pre-tax dollars for eligible health care expenses, including psychiatric evaluations and ketamine treatments. 

Simply enter your HSA or FSA card as your payment method at checkout to take advantage of this option.

The Future Outlook

Expanding insurance for ketamine will be a big step forward, but it’s not without its challenges. With more people using telemedicine and more studies showing how well ketamine works, insurance companies are starting to cover it more. Our work with Enthea shows new ways to make coverage options better, especially for employers that offer it. But, some people still are doubtful on how well and how long these treatments work. To help, we as a field need to show strong proof that they’re effective and fit within healthcare regulations and standard clinical practice. 

The future of ketamine therapy insurance coverage is still bright and filled with potential. As we witness a gradual shift in perception among insurers, patients are encouraged to actively engage in this transformative period. Speaking with your insurance provider about ketamine therapy and its benefits can serve as a powerful grass-roots opportunity to advocate for change. Additionally, supporting non-profits like the Ketamine Task Force can further amplify our collective voice in this movement.

Our team at Wondermed are deeply committed to making ketamine treatments as affordable and accessible as possible. By embracing insurance policies more inclusive of ketamine therapies, we aim to further reduce our already competitive costs, making these groundbreaking therapies available to any and all individuals who may benefit from them. 

If you have any questions about navigating insurance for ketamine treatments with Wondermed, don't hesitate to reach out to our Wondermate team for assistance.

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