When a St. Louis physician decides a patient with stubborn depression should be evaluated for esketamine, there is more than one way to get them there. A direct referral to a certified site, a psychiatry evaluation first, a community behavioral health center, a TRICARE network referral, or a self-pay ketamine clinic: each route works well for some patients and stalls for others. Coverage is usually what decides which.
Written for referring clinicians, this comparison leans on answers from 443 people in our summer questionnaire, which covered ten Midwest states with both sides of the river included. The figures are whole-sample totals, final after validation.
The payer backdrop
Respondents reported their coverage, with multiple answers allowed. The two biggest groups were a near tie, 39 percent on commercial plans and 37 percent on Medicaid; Medicare held 23 percent, TRICARE 5, and the uninsured 9.
Patients also told us how much coverage steers them. Given a pair of picks for what matters in a provider, 85 percent of respondents included insurance and 43 percent a site near home. On a separate question, 65 percent rated coverage a big or deciding factor for trying ketamine or esketamine.
With patients split between public and private coverage and filtering every option through it, the right route depends heavily on what the patient carries.
Route A: direct referral to a certified esketamine site
How it works: you refer straight to a certified treatment center that evaluates and, if appropriate, administers esketamine.
Best fit: patients whose plan the site accepts and whose history clearly suggests treatment-resistant depression.
Medicaid considerations: works well only if the site participates with the patient's specific MO HealthNet or Illinois Medicaid managed care plan. Confirm by plan name.
Commercial considerations: confirm the site is in network with the plan's behavioral health vendor, if one exists, not just the medical network.
Weak point: a mismatch between site and plan sends the patient back to square one.
Route B: psychiatry evaluation first
How it works: you refer to a psychiatrist, who evaluates the full picture and refers onward if esketamine or another treatment fits.
Best fit: patients with diagnostic uncertainty, complex comorbidities, or histories where another approach might come first.
Medicaid considerations: psychiatry access for Medicaid patients can involve waits. Ask the plan for in-network psychiatrists, and consider whether a community behavioral health center can see the patient sooner.
Commercial considerations: often smoother, but behavioral health vendors may have narrow networks.
Weak point: an added step and added time. Patients who are struggling may drop off between referrals.
Patients are not surprised by this route; 23 percent of our respondents would start with a psychiatrist anyway.
Route C: community behavioral health center
How it works: you refer to one of the region's community behavioral health organizations for evaluation and coordinated care.
Best fit: Medicaid and uninsured patients, patients who need broader support, and those without a clear path elsewhere.
Medicaid considerations: these centers generally accept Medicaid and can coordinate onward referrals, including to esketamine sites.
Commercial considerations: less commonly the first choice, but still an option.
Weak point: they may not administer esketamine themselves, so this is often a bridge rather than an endpoint.
Route D: a TRICARE network referral
How it works: for patients covered by TRICARE, you refer to a certified site in the TRICARE network, usually with a referral or authorization through the patient's primary care manager.
Best fit: active duty families, retirees, and others with TRICARE coverage, including the many households in the region connected to Scott Air Force Base.
Payer considerations: TRICARE runs separately from Medicaid and commercial coverage. Some patients carry it alongside another plan, so ask which one pays first.
Weak point: a missing referral or authorization step can stall care for weeks. TRICARE was reported by 5 percent of respondents, a small group that is easy to leave off a referral list entirely.
Route E: self-pay ketamine clinic
How it works: the patient pays directly at a clinic offering IV ketamine infusions or an at-home program.
Best fit: patients with means who prefer speed over coverage, and who understand the regulatory difference.
Payer considerations: generally not covered. For depression, ketamine drips and take-home ketamine are off-label; the FDA approval belongs to esketamine alone.
Weak point: cost, and a different regulatory footing. At-home ketamine involves less direct supervision. If FDA approval matters to the patient, this route may not match their values. Among those we polled, 59 percent said FDA approval would count for a lot or settle the question.
Patient preference here is genuinely mixed: just over half of respondents favored insurance despite extra steps, and the rest split between cash pay and uncertainty.
Side by side, in brief
- Fastest when it works: Route A, if the site takes the plan.
- Most thorough: Route B.
- Most reliable for Medicaid and uninsured patients: Route C as an entry point.
- Specific to TRICARE patients: Route D.
- Least dependent on coverage: Route E, at a price and with a different approval status.
Common threads across routes
Whatever route you choose, three things raise the odds the referral lands. Ask the patient's coverage before naming a site. Include the medication history authorization reviewers look for. And write the treatment's name down, because 73 percent of our respondents had not heard of Spravato. For the packet, Brain Recovery Centers publishes a plain summary of esketamine costs and insurance to include in the packet.
Remember, too, that your recommendation carries unusual weight. In our poll, 74 percent said their own physician's advice is what would get them started. The route you pick is likely the one the patient takes.
Limits of this comparison
This comparison reports whole-sample results only and gives no breakdown by payer or any other group. As market research, it cannot speak to efficacy, and each patient's suitability for esketamine is your clinical judgment.
Every route should come with a crisis resource. Patients moving between referrals need 988 on paper; the Suicide and Crisis Lifeline picks up calls and texts around the clock.
Methodology
Pollfish study 395586438 drew on consumer-panel members and closed June 23, 2026, with 443 completes, each respondent 18 to 64, in Kansas, Illinois, Ohio, Nebraska, Missouri, Minnesota, Oklahoma, Iowa, Indiana and Wisconsin. Coverage was multi-select. Every share here is validated. Funding and the commission for this study came from the site's publisher.