Written by Deborah Tan, Avesta Ketamine Wellness Co-CEO
In this post:
- Ketamine Therapy Costs in DC: How Does It Work?
- Why Do Most DC Insurers Not Cover Ketamine?
- Ketamine Insurance Coverage Options in DC
- DC Ketamine Financial Assistance and Support Options
- The Bottom Line
Ketamine therapy is a proven treatment for challenging mental health conditions, including depression, PTSD, and chronic pain. However, DC ketamine costs can create a significant roadblock, especially since most insurance plans don’t cover IV infusions.
Fortunately, some DC insurance providers offer full and partial coverage for ketamine therapy, depending on the treatment type and plan. Medical assistance programs and private financing options can also offset costs.
Ketamine Therapy Costs in DC: How Does It Work?
Ketamine therapy costs at DC clinics like Avesta vary based on the therapy method (e.g., Spravato nasal spray vs. IV infusion) and specific location. Urban areas like DC may charge more for ketamine therapy due to higher operational and real estate costs. However, due to supply and demand, increased competition in major cities can also drive down prices.
Treatment type is by far the most significant factor affecting ketamine therapy costs in DC and throughout the country.
- Oral Tablets: Oral ketamine tablets are generally the most affordable generic ketamine option, ranging from $75 to $200 per prescription. However, at-home prescriptions are not the safest or most effective method for treating severe mental illness.
- Nasal Sprays: Generic intranasal ketamine sprays vary from $50 to $300 per bottle, with the same at-home drawbacks.
- IV Infusions: Ketamine infusions administered via IV into the veins is the most effective treatment method in DC and nationwide. Infusions are also expensive, ranging from $300 to $2,000 per dose over a six-session protocol.
- Spravato: Spravato is an FDA-approved ketamine-analog nasal spray. Most DC insurers cover Spravato treatment, meaning patients may pay as little as $10 per treatment via a savings program.
Why Do Most DC Insurers Not Cover Ketamine?
Insurance providers in DC and throughout most of the country typically do not cover ketamine therapy because the compound is not FDA-approved for mental health, despite years of clinical data. Ketamine clinicians must administer the compound off-label, so most do not have in-network partnerships with insurers.
Ketamine is used “off-label” for depression and chronic pain.
Decades of clinical research have shown ketamine’s mood-elevating properties, especially for treatment-resistant depression. Additionally, it is safe and effective, according to the open-label trial on ketamine for veterans with PTSD. Still, the FDA has not approved generic ketamine infusions, tablets, or nasal sprays as a mental health treatment. Clinicians who prescribe and administer ketamine are doing so “off-label.”
“Off-label” is a term for drugs prescribed for purposes not explicitly approved by the FDA. A 2001 study showed off-label medicine accounted for about 21% of prescriptions in the United States. Off-label prescriptions allow DC patients to benefit from ketamine’s rapid-acting benefits.
However, most providers do not cover off-label therapies, causing roadblocks for people seeking ketamine insurance in DC. An exception is Spravato, a ketamine derivative that is available as a nasal spray. The FDA approved Spravato in 2019 for treatment-resistant depression and major depressive disorder with acute suicidal ideation. Most major DC insurance companies fully cover Spravato, and patients are responsible for a co-pay only.
Ketamine clinics are often “out of network” with insurers.
Another obstacle to DC ketamine therapy coverage is finding an “in-network” clinic. With a few exceptions, ketamine clinics in DC are generally “out of network,” meaning they do not have a direct relationship or contracts with insurance companies to offer services at negotiated rates.
Typically, out-of-network benefits include higher deductibles, copayments, and more out-of-pocket costs.
- 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 include out-of-network benefits, but costs are higher. Sometimes, patients can request a full or partial reimbursement in the following weeks.
DC’s PPO insurance plans may reimburse ketamine patients for ancillary services, such as diagnostic tests and consultations, even when patients visit an “out of network” clinic. However, reimbursement will be a smaller percentage of the cost.
Meet with an Avesta insurance expert to determine ketamine pricing and coverage options in DC.
Ketamine Insurance Coverage Options in DC
The financial barriers are steep, but full or partial ketamine coverage in DC is possible through insured Spravato treatments, partial reimbursement requests, and financial assistance options.
Full coverage for Spratavo
Most DC insurance companies fully fund Spravato treatments for qualifying patients because of its FDA approval. Eligible patients must receive an FDA-approved diagnosis of treatment-resistant depression or major depressive disorder to qualify.
DC providers that cover Spravato treatment include:
- Aetna
- Cigna
- United Healthcare
- Care First (Blue Cross Blue Shield)
- Medicare
- Medicaid
- Tricare
- Kaiser Permanente
Prior Authorization
DC residents who prefer IV ketamine therapy over Spravato will have a harder time gaining coverage. However, patients can ask their healthcare provider to “pre-authorize” or advocate for the necessity of ketamine treatment directly to the insurance company.
This process requires the patient’s primary care doctor or therapist to submit a request to the insurance company, arguing the medical necessity of IV ketamine treatment. Upon reviewing these requests, insurance companies may approve and agree to fund the treatment ahead of time despite its non-standard status.
Partial reimbursement
In some instances, patients receiving IV ketamine infusions can request that their insurance provider reimburse them for ancillary costs, such as:
- The office visit
- The “evaluation and management” part of the infusion appointment
- Medical monitoring
- Additional medication
A critical step to requesting ketamine therapy refunds is providing superbill codes. Superbill codes, or service codes, are detailed invoices that healthcare providers use to describe the treatments given to a patient. These codes outline each service rendered along with their respective costs. Submitting them sometimes involves the healthcare provider preparing the superbill after a patient’s visit. Patients can then submit this superbill to their insurance company to reimburse out-of-pocket expenses for treatments not directly billed by the healthcare provider.
Avesta’s DC, Virginia, and Maryland clinics make this process easier by offering patients free access to reimbursement software, Reimbursify.
DC Ketamine Financial Assistance and Support Options
DC patients without traditional insurance coverage may be able to obtain accessible ketamine therapy through private and public financial assistance programs.
1. Medicaid and medical assistance programs
DC residents without private insurance benefits can seek financial aid through medical assistance programs like the Health Care Alliance and DC Medicaid. These programs provide eligible residents with health coverage and financial assistance based on income, age, or disability status.
2. Veterans Affairs (VA) Coverage
Avesta’s DC ketamine clinic is a VA-approved ketamine therapy provider, offering in-network care through the VA (Veterans Affairs). Its VA partnership means that eligible veterans in the area can access ketamine for free. DC veterans with VA coverage should contact their offices and request a referral to Avesta for IV ketamine or Spravato treatments at its Washington DC clinic.
3. HSA/FSA accounts
Health Savings Accounts (HSAs) and Flexing Spending Accounts (FSAs) allow patients to set aside pre-tax dollars for qualified medical expenses, such as ketamine therapy. Patients in DC must be enrolled in a high-deductible health plan (HDHP) to be eligible to open these accounts. They must also provide documentation that verifies ketamine as an eligible expense.
4. Private financing options
Ketamine clinics, like Avesta’s DC location, offer several private financing options through healthcare credit cards. These payment methods help DC patients avoid the stress of upfront costs and pay the expenses in affordable increments.
- Advanced Care: Avesta’s clinic in DC has a strategic partnership with Advance Care, which offers flexible plans with manageable monthly payments and interest-free financing.
- Care Credit: Avesta also partners with CareCredit, another reputable financing company that provides a range of short-term plans featuring low-interest and interest-free options with fixed monthly payments.
The Bottom Line
Ketamine therapy in DC can present a problematic financial hurdle for many residents because most insurance plans won’t cover this “off-label” therapy. However, there are options to help DC patients fund ketamine treatment, including full Spravato coverage, partial IV coverage, medical assistance, pre-tax healthcare savings accounts, and healthcare credit cards.
DC patients hoping to take advantage of this fast-acting and effective treatment method for depression, PTSD, and chronic pain can contact Avesta’s D.C. ketamine clinic for a free consultation with its insurance experts.
