Getting a ketamine prescription starts with a diagnosis that qualifies you for treatment, most commonly treatment-resistant depression or chronic pain that hasn’t responded to standard therapies. The path you take depends on whether you’re seeking the FDA-approved nasal spray (esketamine, brand name Spravato) or off-label ketamine through a specialty clinic or telehealth provider. Each route has different requirements, costs, and levels of medical oversight.
Who Qualifies for Ketamine Treatment
The most common qualifying condition is treatment-resistant depression, which generally means your depression hasn’t improved after trying at least two different antidepressants, each taken at adequate doses for at least eight weeks. Roughly half of people with major depression don’t achieve remission after two treatment attempts, so this isn’t a rare designation.
Spravato, the only FDA-approved ketamine-based product for psychiatric use, is specifically indicated for two groups: adults with treatment-resistant depression, and adults with major depressive disorder who are experiencing acute suicidal ideation or behavior. For the second group, you don’t need a history of failed antidepressants, but Spravato must be paired with an oral antidepressant.
Off-label ketamine (the original drug, not esketamine) is also prescribed for chronic pain conditions like complex regional pain syndrome, neuropathic pain, and fibromyalgia. Cleveland Clinic’s pain program, for example, considers patients who have been suffering for six months or more and have exhausted standard treatments. There is no FDA-approved psychiatric indication for ketamine itself, only for esketamine.
The FDA-Approved Route: Spravato
If you’re pursuing the FDA-approved nasal spray, your psychiatrist or referring physician will need to document your depression diagnosis and your history of failed antidepressant trials. Most insurers require a baseline score on a standardized depression questionnaire like the PHQ-9 before approving coverage. The prescribing provider or their clinic must be certified in the Spravato REMS program, a federal safety framework that controls how the drug is dispensed.
You cannot take Spravato home. Every dose is self-administered under direct supervision at a certified healthcare setting, and you’re monitored for at least two hours afterward for changes in blood pressure, sedation, and dissociation. This means regular visits to a clinic, typically twice a week during the first month, then weekly or biweekly. Insurance authorization is usually granted for up to 12 months at a time.
Spravato is contraindicated if you have certain vascular conditions (aneurysms or arteriovenous malformations), a history of bleeding in the brain, or an allergy to ketamine. It’s not approved for anyone under 18 or recommended during pregnancy.
Off-Label Ketamine Through a Clinic
Many ketamine clinics operate outside the Spravato system, offering IV infusions, intramuscular injections, or compounded forms like lozenges (troches) and nasal sprays. Because ketamine itself isn’t FDA-approved for depression or pain, these treatments are considered off-label. Any licensed physician can legally prescribe ketamine off-label, but the American Society of Anesthesiologists recommends it only be prescribed as part of a comprehensive treatment plan by an appropriately trained provider with periodic face-to-face visits.
Before your first treatment, expect a thorough intake process. Clinics typically require a comprehensive psychiatric or medical evaluation, a review of your treatment history, a physical exam, and baseline lab work including liver function tests and kidney function markers. You’ll likely complete a urine drug screen and fill out standardized mood assessments. Depending on your medical history, you may need additional clearance from a cardiologist, neurologist, or other specialist.
For IV ketamine targeting chronic pain, a common protocol involves 0.5 mg/kg infused over 40 minutes for five consecutive days at an outpatient infusion center. Depression protocols vary more widely but often follow a similar low-dose approach. The only absolute contraindication at these doses is pregnancy, though a history of ketamine abuse or addiction is generally a disqualifying factor.
Telehealth and At-Home Prescriptions
Several telehealth companies now prescribe compounded ketamine (usually lozenges or nasal sprays) for at-home use after a video consultation. This is possible because the DEA has extended COVID-era telemedicine flexibilities through December 31, 2026, allowing practitioners to prescribe Schedule III controlled substances like ketamine without an in-person visit, provided the prescription serves a legitimate medical purpose.
This is the easiest access point, but it comes with important trade-offs. Compounded ketamine products are not FDA-approved, meaning there’s no established dosing regimen, no standardized safety data, and no required monitoring program like the one governing Spravato. The FDA has specifically warned about compounded ketamine nasal sprays, noting that most adverse event reports involved patients self-administering at home without professional observation. Reported doses of compounded nasal sprays have varied enormously, from three sprays three times daily to six sprays eight times daily.
Animal studies have also shown that racemic ketamine (the form used in compounded products) can cause brain lesions in rodents, a finding not seen with esketamine. Whether this applies to humans at therapeutic doses remains unknown, but it’s one reason the FDA draws a distinction between the two drugs.
Insurance Coverage and Costs
Insurance is far more likely to cover Spravato than off-label ketamine. UnitedHealthcare, for example, covers Spravato for treatment-resistant depression when prescribed by or in consultation with a psychiatrist at a REMS-certified facility. The same insurer classifies ketamine injections for psychiatric disorders, chronic pain, and migraines as “investigational” and does not cover them. Most major insurers follow a similar pattern.
Out-of-pocket costs for IV ketamine infusions typically run several hundred dollars per session, and a full initial course may involve four to six sessions over two to three weeks. Compounded ketamine through telehealth services tends to be less expensive per dose but is also entirely out of pocket. Even with Spravato coverage, copays and prior authorization requirements vary widely by plan, so confirming your benefits before starting treatment is essential.
What to Look for in a Provider
Not all ketamine clinics meet the same safety standards. The American Society of Anesthesiologists recommends that IV, intramuscular, or intranasal ketamine for mental health conditions be administered only under the supervision of a physician who is immediately available, familiar with ketamine’s full range of effects, and working in a setting with rescue equipment on hand. Ketamine should be prescribed at the minimum effective dose and should not produce unconsciousness or unresponsiveness outside of anesthesia settings.
When evaluating a provider, ask whether they perform a full medical and psychiatric evaluation before treatment, require lab work, use standardized mood assessments to track your progress, and have protocols for managing side effects like nausea, elevated blood pressure, or dissociation. A clinic that skips these steps or offers treatment without reviewing your medication history is cutting corners that exist for your safety.