Most referral workflows for esketamine were built around a patient with a commercial plan. The patient panel, at least in our survey, does not look like that. What follows helps referring clinicians make esketamine referrals land, whatever coverage the patient carries.

The starting point is our summer poll, in which 443 adults across ten Midwest states described their coverage, more than one answer allowed. Commercial plans came to 39 percent against 37 percent for Medicaid. Medicare, at 23 percent, came next; 9 percent were uninsured and 5 percent carried TRICARE. Every figure is final.

The practical meaning of near-parity

A two-point margin between commercial and Medicaid coverage is noise. What matters is that the two are about equal. If your referral process works smoothly only for commercial plans, it may work smoothly for well under half of the patients who could benefit from it.

That matters because, in the same survey, coverage was overwhelmingly what people weighed first. Given two picks, 85 percent of respondents put insurance among what they want in a provider, and almost two thirds, 65 percent, told us coverage could settle, or strongly steer, their decision to try the treatment.

A quick refresher on the treatment

Spravato, the esketamine nasal spray, is indicated in adults for treatment-resistant depression, with distribution limited to a REMS program. Patients take each dose while staff watch at a certified setting, remain for two hours or more, and avoid driving or machinery until after a night's sleep. Sedation, dissociation, and blood pressure increases are among the effects monitored.

Infused ketamine and telehealth ketamine taken at home both fall outside any depression approval. The two are frequently confused by patients, and they differ in regulatory status and in how payers treat them.

How the payer changes the referral

Medicaid. Most states administer Medicaid through managed care organizations, each with its own network and prior authorization criteria. One certified site can be in network with one managed care plan and out with the next, so "does this site take Medicaid?" is the wrong question. The right one is "does this site take this patient's specific plan?"

Commercial. Employer plans frequently carve out behavioral health to a separate vendor. The medication and the observation visit may also be billed under different benefits. A site can be in network on the medical side and out on the behavioral side.

Medicare. The combination of a drug and a supervised service can span more than one part of the program, and Medicare Advantage plans add their own networks and authorization rules. Sites with established Medicare volume tend to navigate this more reliably.

TRICARE. Specialty care often requires a referral through a primary care manager. Missing it delays everything.

Uninsured. Some patients may be newly eligible for Medicaid. A prompt to check eligibility, or a referral to a navigator, can be worth more than a clinic name.

What prior authorization reviewers commonly look for

Criteria vary by plan and state, but reviewers for esketamine often ask for some combination of:

An adult major depressive disorder diagnosis.
Documented trials of other antidepressants, with names, doses, durations, and outcomes.
Evidence the patient will be treated at a site certified to give Spravato.
Sometimes a standardized severity measure, such as a depression rating score.

Referrers are often the best source for the medication history, because it lives in your chart. A concise summary sent with the referral can shorten the authorization process at the receiving site.

Why your role matters more than any outreach

The survey was unusually clear on this. Physicians were the most persuasive voice at 74 percent, friends and family followed at 18 percent, and online figures and ads scarcely registered. The opening move would be primary care for 56 percent and psychiatry for 23 percent.

That influence cuts both ways. A well-matched referral carries enormous weight. A mismatched one, to a site that cannot take the patient's plan, may be the last attempt a depleted patient makes for a while.

Patients will accept friction if coverage waits at the end

One more finding should reassure referrers worried about burdening Medicaid patients with paperwork. Offered insured care with extra steps or simpler cash pay, 51 percent of respondents picked the insured option, 23 percent the cash option, and 26 percent were unsure. Patients can read the Brain Recovery Centers primer on esketamine costs and coverage that referrers can pass along. Friction is tolerable. Dead ends are not.

Logistics that disproportionately affect coverage-dependent patients

The observation period and the no-driving rule are the same for everyone, but they weigh more on patients without flexible work hours or a second car. Two points worth raising at referral:

Many Medicaid managed care plans cover non-emergency medical transportation. Patients often do not know.
Proximity matters to patients: in our survey, 43 percent named a nearby site among their two leading provider priorities, second only to coverage. A covered site that is far away may need a conversation about how the patient will sustain the visit schedule.

A simple habit helps here: when a patient reports that a referral fell through because of coverage, note which plan and which site. Over a few months those notes become a practical map of where your patients can actually be seen.

Caveats

This article reports whole-sample figures. It describes the overall payer mix among respondents and does not break any other answer down by payer. It is market research, not clinical evidence, and says nothing about efficacy or about the suitability of esketamine for any individual patient. Those judgments remain yours.

Please consider including crisis resources in any referral handout. Patients waiting on an authorization should know the number 988; the Suicide and Crisis Lifeline answers there by voice or text at every hour.

Methodology

Data come from Pollfish study 395586438, a consumer-panel survey closed June 23, 2026: 443 respondents, 18 to 64, from Ohio, Iowa, Missouri, Kansas, Minnesota, Nebraska, Illinois, Indiana, Oklahoma and Wisconsin. The coverage item allowed multiple answers. Its whole-sample shares have cleared validation. The publisher initiated the study and paid for it.

What a Medicaid-heavy payer mix means for esketamine referrals