A retired Marine in Florissant, a Guard member in Arnold, a firefighter's wife in Belleville, and an Air Force family near Scott. Four patients, four different ways into depression care. For St. Louis referrers, the hardest part of helping military-connected patients is often not the clinical decision. It is picking the right door.
This comparison lays out the main routes side by side, drawing on our commissioned survey of 443 Midwest adults for the patient's side.
What patients prioritize
We asked respondents to choose the two factors that would matter most when picking a provider for ketamine or esketamine therapy. Coverage by insurance led at 85 percent. Close to home was 43 percent. Specialization in veterans and first responders came last, at 10 percent.
We also asked about coverage. TRICARE was 5 percent of the multi-select payer mix; commercial reached 39 percent, Medicaid 37 percent, and Medicare 23 percent. For a first stop, 56 percent would pick their primary care doctor.
These are top-line figures from a regional sample, validated and final. Service members themselves were too few to break out; this piece says nothing about veterans' own preferences. What the figures do suggest is that coverage and distance should drive route selection, and that the civilian referrer is often the first contact.
Route 1: TRICARE with a civilian provider
Who it fits: Active duty families, military retirees and their families, and some Guard and Reserve members.
How it works: The patient sees a TRICARE-authorized provider. Referral and authorization rules differ by plan type and service.
Strengths: Many St. Louis-area civilian providers participate. For families near Scott AFB, this is often the most practical route.
Tradeoffs: Plan-specific rules. Missing a required referral can mean a denied claim.
Your role: Confirm plan type and requirements before scheduling.
Route 2: Employer and commercial plans
Who it fits: Veterans covered through their own job or a spouse's, most first responders, and military spouses with coverage at work.
How it works: The standard in-network referral. The destination bills the plan, and interventional treatments such as esketamine usually need prior authorization.
Strengths: Broad networks across the metro, and a member services line that can answer coverage questions before the first visit.
Tradeoffs: Deductibles and coinsurance can bite early in the plan year. Network status for certified centers varies by plan.
Your role: Send the medication history the insurer will ask for, and give the patient specific questions to put to member services.
Route 3: Medicaid
Who it fits: Veterans, family members, and first responder households who qualify. In Missouri the program is MO HealthNet; Metro East residents use Illinois Medicaid.
How it works: The patient needs a destination that accepts their specific plan. Prior authorization for interventional treatment is common.
Strengths: Low out-of-pocket cost for the patient. Medicaid and commercial plans together make up the bulk of the payer mix in our data.
Tradeoffs: Fewer participating destinations in some parts of the metro, and approval can hinge on documented medication trials.
Your role: Confirm plan acceptance before the patient gets their hopes up, and ask the plan whether help with rides to appointments is available.
Route 4: Medicare
Who it fits: Older military retirees, older veterans, and people who have Medicare through disability.
How it works: The standard Medicare referral path. For retirees who also carry TRICARE For Life, Medicare usually pays first and TRICARE follows.
Strengths: Predictable rules and wide acceptance among established practices.
Tradeoffs: Medicare Advantage plans may add their own network limits and authorization steps.
Your role: Confirm whether the patient is on original Medicare or an Advantage plan before choosing a destination.
Route 5: Cash-pay ketamine programs
Who it fits: Patients who choose to pay out of pocket, sometimes after seeing programs marketed to veterans.
How it works: IV infusion clinics or at-home telehealth ketamine, both off-label for depression and PTSD.
Strengths: Can be fast to start.
Tradeoffs: No FDA approval for these uses, variable oversight, and at-home programs involve much less monitoring than a certified esketamine site. Across our full sample, 23 percent of respondents said they would rather pay themselves for a simpler path, while just over half preferred covered care even with hoops.
Your role: If a patient is considering this, make sure they understand how it differs from FDA-approved esketamine.
Where esketamine sits across routes
Spravato, the esketamine spray, has FDA approval in adult treatment-resistant depression; administration is limited to certified centers, which watch each patient after the dose. Depending on coverage, it may be reachable through several of the routes above. A walk-through of a typical Spravato visit can help patients picture it. It is not approved for PTSD, so for patients whose main problem is trauma, a referral should also secure trauma-focused therapy.
A quick way to choose
- TRICARE beneficiary: Route 1, with plan rules confirmed.
- Veteran, spouse, or first responder with a work plan: Route 2.
- Patient on MO HealthNet or Illinois Medicaid: Route 3.
- Retiree on Medicare, with or without TRICARE For Life: Route 4.
- Patient drawn to cash-pay programs: a careful conversation before Route 5.
Whatever the route, check the drive. With 43 percent ranking proximity among their top priorities, and treatments that can involve frequent early visits, a destination across the metro may not be sustainable.
It also helps to ask the patient which route they would pick if cost were equal. Some patients carry two kinds of coverage and have strong feelings about one of them, and a route the patient resents is a route they may quietly abandon after the first visit.
What does not change
Across every route, the clinician's recommendation matters most. Their own doctor was the voice that would get 74 percent of respondents to try something new; just 4 percent handed that role to veteran or first responder accounts they follow online. Pick the route, then say plainly that you think the patient should take it.
No route should delay crisis care. Anyone in St. Louis is one call or text away from the Suicide and Crisis Lifeline at 988, whatever the hour; veterans can press 1.
Methodology
These survey figures rest on a study we ran through the Pollfish consumer panel, fielded until June 23, 2026. Its respondents numbered 443, ages 18 to 64, from ten states in the Midwest, Missouri and Illinois among them. We report top-line results, the payer question was multi-select, and every figure is from the validated final data. Our publisher both commissioned the study and covered its cost. Route descriptions are general and should be confirmed with TRICARE and the patient's plan.