Blue Cross Blue Shield (BCBS) is one of the country’s leading providers of healthcare. In 2023, BCBS had 115 million members, accounting for nearly 1 in 3 Americans.
While state-to-state programs vary, most BCBS plans cover the costs of Spravato, a ketamine-based treatment. Some state programs, including BCBS Arizona (BCBSAZ), also offer coverage for other forms of ketamine therapy, such as intravenous infusions. However, this tends to be limited.
In this article, we’ll help you understand more about BCBS and insurance coverage for ketamine and Spravato in Phoenix, AZ.
Does BCBS Cover Ketamine Treatment Costs in Arizona?
Ketamine therapy at Kadelyx combines the benefits of ketamine with personalized therapeutic support to promote healing and personal growth. We offer treatment either intravenously (IV) or intramuscularly (IM) for fast-acting results.
While ketamine itself has been FDA-approved for decades as an anesthetic, its use for mental health conditions is considered “off-label.” This means it is prescribed for a purpose other than the one for which it’s approved.
Because of this off-label status, insurance coverage is often limited, and many insurers don’t cover ketamine costs when used for mental health purposes. Currently, BCBSAZ does not offer full coverage for off-label ketamine use. However, some plans may provide partial coverage for certain associated medical services, such as office visits and monitoring.
If you wish to seek reimbursement from your insurance, Kadelyx can issue a superbill, an itemized invoice that can be directly submitted to BCBS to request coverage of eligible costs.
Does BCBS Cover Spravato Treatment in Arizona?
Spravato (esketamine) is a nasal spray derived from ketamine and is FDA-approved for treatment-resistant depression (TRD) and major depressive disorder with suicidal thoughts or actions (MDSI). Kadelyx is a registered provider of Spravato, administering the medication in a safe and controlled setting, in strict accordance with FDA guidelines.
Because Spravato is FDA-approved, many insurance plans, including BCBSAZ, do cover this treatment. However, patients must meet the necessary medical criteria, which involves an official diagnosis of TRD and MDSI.
Kadelyx is proud to be an in-network provider for Spravato with BlueCross BlueShield of Arizona. This means eligible patients can receive Spravato treatment with coverage from their BCBSAZ plan.
Out-of-Pocket Costs
Although BCBS covers the medication costs of Spravato, patients may still be responsible for:
- Plan deductibles
- Co-pays or coinsurance
- Costs for missed or rescheduled appointments
We will review your plan’s details with you before treatment so you have a clear understanding of your costs.
How to Verify BCBS Coverage for Ketamine Treatment
The best way to confirm your benefits is to contact BCBSAZ directly or allow Kadelyx’s administrative team to assist you. Here’s what you’ll typically need:
- Your insurance ID number
- Your plan details (HMO, PPO, etc.)
- A statement from your provider about medical necessity
- Procedure and diagnosis codes (provided by Kadelyx)
For Spravato coverage, you’ll need to have an official diagnosis of TRD or MDSI. To be diagnosed with TRD, you’ll have tried at least two different types of antidepressants for at least six months each with no significant benefits. For MDSI, you’ll have a clinical diagnosis of MDD, without psychotic features, and be deemed to be at risk of suicide by a registered clinician.
Support for Navigating Insurance at Kadelyx
Insurance details can be complicated, but our team at Kadelyx is here to support you. We can:
- Explain your coverage options
- Provide necessary documentation
- Submit pre-authorization requests (when required)
- Help you understand potential out-of-pocket costs
For further information or advice, contact our team today.
