Written by Deborah Tan, Avesta Ketamine Wellness Co-CEO
In this Post:
- How Does Ketamine Therapy Work?
- Why Do Most Virginia Insurers Not Cover Ketamine?
- Avesta’s In-Network Options
- Ketamine Coverage and Financing Options in Virginia
- Which providers cover ketamine treatment in Virginia?
- Can I use my insurance anywhere in Virginia for ketamine treatments?
- Which medical assistance programs help with insurance and bills in Virginia?
- Are there financing options outside of insurance for ketamine in Virginia?
- What is the application process for requesting coverage?
- The Bottom Line
Ketamine is an emerging therapy proven to relieve treatment-resistant conditions, including depression, PTSD, and chronic pain. However, the high infusion cost is often a hurdle for Virginians hoping to benefit from this fast-acting medicine. Many patients want to know how to get ketamine insurance in Virginia to help offset these costs and get the healing they need.
This article guides patients seeking ketamine insurance coverage in Virginia and explores financial assistance to make treatment more affordable.
Ketamine Therapy in Virginia: How Does it Work?
Virginia ketamine therapy centers, like Avesta’s McLean VA clinic, are relatively new. But ketamine research is not. The treatment has decades of clinical research behind it, showing that supervised ketamine therapy is safe and effective for chronic pain and mental health–notably for treatment-resistant depression.
In 2018, the National Center for Biotechnology Information reported that repeated ketamine infusions administered under clinical guidance display minimal risk of adverse effects.
Virginia ketamine clinics offer several forms of treatment. Ketamine infusion therapy administered via IV into the veins is the most common in Virginia and nationwide due to its effectiveness. Unfortunately, IV also tends to be the most expensive method because it involves numerous medically monitored sessions over several weeks.
Ketamine therapy also comes in other medication forms, including:
- Nasal sprays
- Troches (or lozenges)
- Subcutaneous infusions (under the skin)
- Intramuscular infusions (into the muscle)
Some doctors prescribe compounded ketamine sprays and lozenges for at-home use. These administration methods are generally more affordable than clinical ketamine treatments, but they come with increased risks of abuse, misuse, and adverse psychiatric effects. Avesta only prescribes at-home ketamine under specific circumstances with a complete medical management picture in mind.
Why Do Most Virginia Insurers Not Cover Ketamine Therapy?
Virginia residents hoping to have ketamine treatment covered by insurance often have difficulty. Insurance does not usually cover ketamine therapy in most areas, including Northern Virginia, for a few reasons:
Ketamine is “off-label”
Ketamine has been around since the 1960s when the FDA approved it as an anesthetic and pain reliever. However, ketamine is not approved as an antidepressant despite decades of research. In Virginia, ketamine prescriptions for depression, chronic pain, PTSD, and other mood disorders are considered “off-label.” This term is used for drugs prescribed for purposes not explicitly approved by the FDA.
Off-label drugs like ketamine are incredibly common, and a study in 2001 showed they accounted for about 21% of prescription medications in the United States. Still, the off-label status causes roadblocks for people seeking Virginia ketamine insurance.
An exception is Spravato, known generically as esketamine. Spravato is a nasal spray approved by the FDA for treatment-resistant depression and major depressive disorder with acute suicidal ideation. It is a derivative of ketamine. The FDA approved Spravato in 2019, so most major Virginia insurance companies will cover most of the treatment cost.
Ketamine clinics are often “out of network”
Most Virginia ketamine clinics are out of network with insurance companies, adding a layer of complexity to the coverage process. Being “out-of-network” means these clinics do not have contracts with the given insurance company to provide medical services at negotiated rates.
Out-of-network ketamine clinics in Virginia can affect patients differently, depending on their insurance plan:
- HMO insurance plans usually limit coverage to care from doctors who work for or contract with the HMO, so they rarely cover out-of-network care.
- PPO plans do include out-of-network benefits, but patients usually pay more of the cost. In these cases, patients can pay the clinical provider “out of pocket” using their finances while requesting a full or partial reimbursement in the following weeks.
In some cases, out-of-network insurance plans or those that don’t cover ketamine might provide partial coverage for other parts of ketamine therapy, like consultations and diagnostic tests.
Avesta’s In-Network Exceptions
Avesta understands that these treatments can be cost-prohibitive for people who desperately need this life-saving medication. One of our primary goals is to expand access to ketamine IV infusions. As such, Avesta is researching how to go in-network with insurance providers in the Virginia, Maryland, and D.C. areas and will hopefully soon be in-network with select payers.
In addition, Avesta is proud to announce that they are now in-network with the VA (Veterans Affairs). Virginia veterans with VA coverage should contact their offices and request a referral to Avesta for IV ketamine and Spravato treatments in its McLean Clinic.
Avesta has also received Workman’s Compensation Coverage approval.
Northern Virginia veterans and residents can request a free consultation with Avesta’s insurance team to discuss coverage options.
Ketamine Coverage and Financing Options in Virginia
Despite insurance challenges, Virginia patients have successfully obtained full or partial ketamine therapy coverage. Insurance providers make decisions based on several factors, including the type of ketamine used and the medical necessity.
Avesta’s insurance experts help patients seeking ketamine therapy insurance and financing options in Virginia with the following common questions:
Do insurance providers cover ketamine treatment fully or partially in Virginia?
Some Virginia insurance providers cover ketamine therapy costs for patients who can prove the medical necessity. Prior authorization requires the patient’s healthcare provider to submit official documents citing their diagnosis and prior failed attempts to treat the condition. Patients who receive prior approval for ketamine therapy might only be responsible for a co-pay for their consultation or therapy services.
Additionally, insurance companies in Virginia can cover nearly 100% of Spravato treatment sessions due to the medication’s FDA approval status. Patients can pay as little as $10 per treatment plus co-pay costs.
Even if a patient’s insurance does not cover ketamine, they may be eligible for reimbursement on ancillary treatment costs, including:
- The office visit
- The “evaluation and management” part of the infusion appointment
- Medical monitoring
- Additional medication
Clinics like Avesta can facilitate insurance reimbursement by providing patients with ketamine superbill codes before treatment. These codes, which describe the ancillary medical services, allow patients to contact their insurance providers in advance to inquire about potential refunds. This pre-treatment step helps patients understand their financial responsibility and the likelihood of compensation.
What specific insurance providers include ketamine treatment coverage in Virginia?
Virginia insurance companies that offer coverage for esketamine (Spravato) treatments in Virginia include:
Additionally, Virginia veterans may be eligible for IV ketamine infusion coverage through the VA:
For veterans seeking IV ketamine coverage, recent updates indicate that the VA now recognizes the treatment’s effectiveness for major depressive disorder and reimburses it under Veterans Care Agreements. With about 21 VA facilities providing ketamine treatments and community care referrals available for those more than 40 minutes away, veterans have improved access. This policy change acknowledges ketamine’s potential benefits in suicide prevention and expands options for veterans with treatment-resistant depression.
Avesta is proud to be one of the VA’s newest in-network ketamine therapy providers for Veterans in the McLean area.
Can I use my insurance anywhere in Virginia for ketamine treatments?
Many ketamine clinics in Virginia are out of network with insurance plans, so most providers will not cover or reimburse ketamine treatment everywhere in Virginia. Patients should inquire with their medical provider in advance to verify coverage for ketamine therapy.
What programs help with insurance and medical bills in Virginia?
Virginia offers several medical assistance programs, each covering different groups of people and having unique eligibility requirements. Those applying for medical assistance will be screened for all possible programs based on age, income, financial resources, and other information. Patients who qualify for Virginia Medicaid might receive coverage or reimbursement for all or parts of their ketamine treatment, depending on the method.
VCU Medical Center, which provides ketamine therapy as part of its mental health treatment, also offers financial assistance for medical bills, including discounts for patients who pay out of pocket, free care to patients below the federal poverty level, and state-run Medicaid and FAMIS programs.
Are there financing options outside of insurance for ketamine in Virginia?
Outside of insurance, Avesta ketamine centers offer financing to help cover costs:
- Avesta’s Virginia clinic works with Advance Care, which has offered interest-free financing options since 2008. Their programs provide affordable monthly payments with flexible terms.
- The Avesta ketamine clinic in Virginia also provides Reimbursify, a free service for patients designed to work with insurance companies to maximize reimbursement. Many patients have reported getting 20% to 80% back from their insurance.
What is the application process for Virginia ketamine insurance coverage?
The insurance application process in Virginia varies based on the type of insurance a person has.
Patients in Virginia with private, VA, or employer insurance can contact their provider before starting ketamine treatment to ask about coverage options for Spravoto and off-label IV ketamine therapy.
Those without employer insurance can create an account on the Virginia Insurance Marketplace and shop for affordable healthcare plans. Open enrollment runs from November 1 to January 15, or special enrollment periods exist for qualifying life events.
The Bottom Line
Virginia ketamine insurance is rare because most insurance companies offer limited coverage for ketamine treatment, if at all. However, there are ketamine clinics in Virginia that work with insurance plans to cover certain types of ketamine treatments and reduce insurance bills, along with offering financing options for patients. Patients in Virginia without insurance can shop for affordable options via the Virginia Insurance Marketplace and other state-run programs.
Avesta offers cutting-edge treatment plans using ketamine therapy and assists many patients with insurance reimbursement and financing for ketamine services. Before giving up on relief, contact Avesta for a free consultation to explore treatment and payment options.