Medicaid Coverage of Esketamine and Ketamine Therapies: Cross-Sectional Policy Analysis Across 51 Jurisdictions and 165 Coverage Entities (August 2025)

 

Esketamine (Spravato) is covered by 75/165 entities (45.5%; 72/75 with prior authorization), while 90/165 (54.5%) are Not Stated; alternative ketamine routes are effectively unavailable (IV 1/165 [0.6%], IM 0, oral largely Not Stated), and six jurisdictions have no covering entities.

 

Objective: Quantify real-world Medicaid access to ketamine therapies by comparing coverage decisions across all policy-making entities inside each state. 

 

Findings: Coverage for esketamine (Spravato) appears in 75 of 165 entities (45.5%); 90 of 165 (54.5%) are Not Stated. Among covering entities, 72 of 75 (96%) require prior authorization. Six jurisdictions have no covering entities at all. Because MCOs control 100 of 165 decision points (60.6%), intrastate inconsistencies are common-states may publish a policy that covers Spravato while one or more in-state MCOs do not-creating confusion and unequal access based on plan assignment. 

 

Alternative routes used for treatment-resistant depression are effectively unavailable: IV is covered by 1 of 165 entities (0.6%), IM by 0, and oral is largely Not Stated. Net effect: 98.2% of entities require some form of individual review before treatment proceeds.