Say you live in St. Charles, you do not have health insurance, and after years of depression that the usual medicines have not touched, you have just learned that a treatment called esketamine exists. You now face a fork in the road. Do you pay out of pocket and try to start soon, or do you get covered first and go through the insurance process?
There is no universal right answer. This comparison lays out what each road looks like, so you can pick with open eyes.
First, a word on the treatment
Spravato, the brand name for this esketamine nasal spray, carries FDA approvals for adults whose depression other treatments have not relieved and for adults facing major depression alongside acute suicidal thoughts or behavior. It lives only inside certified treatment centers: staff watch while you use the spray, keep you at least two hours, and you do not drive until the following day.
Most people have never heard of it. Of 443 Midwest adults in a survey our publisher funded, 73 percent did not recognize the name Spravato at all, 21 percent had heard the word and nothing more, and 6 percent could describe it. The figures are final.
That low awareness matters here. If you only recently learned the name, you may also be hearing about several related options at once, and some of them are much easier to buy with cash than others. A short explainer on Spravato's approved use can help sort them.
How people in our survey leaned
We asked respondents a direct version of this very question: would they rather have insurance coverage for the treatment with more hoops to jump through, or pay themselves for a simpler, faster start? Fifty-one percent preferred coverage with hoops. Twenty-three percent preferred to pay. The final 26 percent were not sure.
So more than twice as many people chose the covered road as the cash road, and a sizable group did not know which way to go. People without insurance, 39 respondents in all, were less sold on it: 38 percent chose the covered road. If you are torn, you have company. Keep in mind that the uninsured group is small. It is large enough to report, but a few answers either way would move its numbers.
Road one: pay now
What it looks like. You find a provider who accepts self-pay patients, get evaluated, and if the clinician agrees, start treatment. For esketamine specifically, that means a certified center willing to see you without insurance. For off-label options, it could mean a ketamine infusion clinic or an at-home telehealth program.
Advantages.
- You may be able to start sooner, without waiting on an application or prior authorization.
- Fewer forms and fewer gatekeepers.
- You control the choice of provider.
Drawbacks.
- Cost is the obvious one. Esketamine carries a high list price per dose, and a course runs many sessions over several months.
- Cash-pay options that look cheaper are often not esketamine. IV ketamine and at-home ketamine are off-label for depression, and at-home use has no in-person monitoring.
- If money runs out partway through, treatment may stop before a clinician would want it to.
What to ask. Is this esketamine or ketamine? Is it FDA-approved for my condition? What is the total cost of a full course, in writing? Is there a manufacturer assistance program I can apply for?
Road two: get covered first
What it looks like. You apply for coverage, then pursue treatment through that plan. For many St. Charles County residents with low incomes, that means MO HealthNet, which Missouri's Medicaid expansion opened to more working-age adults. For others, it means a marketplace plan, possibly with income-based subsidies, or coverage through a new job.
Advantages.
- Much lower out-of-pocket costs if the plan covers the treatment.
- Coverage for the rest of your care too: primary care, therapy, other medications, and lab work.
- For Medicaid members, a plan may offer non-emergency medical transportation, which matters because you cannot drive after an esketamine session.
Drawbacks.
- It takes time. Applications, enrollment dates, and plan start dates can add weeks.
- Plans commonly require prior authorization for esketamine, which means documenting the antidepressants you have tried.
- Coverage has to be maintained, including Medicaid renewals and marketplace premium payments.
What to ask. Is esketamine covered? Does it need prior authorization? Which certified centers are in network near St. Charles? What documentation will my prescriber need?
Why coverage weighs so heavily
In our survey, insurance was the dominant factor in choosing where to get care. When respondents picked their top two priorities, 85 percent included coverage, far ahead of closeness to home at 43 percent. For 65 percent, whether they tried the treatment would turn on coverage, fully or largely.
That is not surprising. Depression treatment that works tends to continue for a while. A cost you can manage once may not be one you can manage twenty times.
A third road: travel both
Nobody says you must pick one road and drop the other. A practical approach for many people in St. Charles:
- Start a coverage application today, through the state for MO HealthNet or through HealthCare.gov.
- At the same time, get evaluated at a sliding-scale clinic. Federally qualified health centers serve St. Charles County and the wider St. Louis area; search findahealthcenter.hrsa.gov.
- Build your medication history list, which you will need on either road.
- If a clinician says esketamine is appropriate, ask the certified center about self-pay costs and manufacturer assistance while your coverage decision is pending.
That way the evaluation is not waiting on paperwork, and the paperwork is not waiting on the evaluation.
The decision that is not yours alone
Whichever road you take, whether esketamine is right for you is a medical question. Blood pressure, certain vascular conditions, and other factors can rule it out. A clinician who knows your history should make that call with you.
If money stress and depression have piled up to the point where you are thinking about suicide, stop and reach out now. Texts and calls to 988 go through to the Suicide and Crisis Lifeline whatever the hour; they cost nothing, need no insurance, and let veterans press 1.
Methodology
We ran the survey with Pollfish's consumer panel and closed it on June 23, 2026. Respondents, 443 in all, were 18 to 64 and came from Iowa, Illinois, Ohio, Missouri, Kansas, Minnesota, Oklahoma, Nebraska, Wisconsin, and Indiana. Figures are whole-sample except the uninsured split, with no county breakdowns, and all come from the final validated export. The study was commissioned by the publisher, who covered the full bill.