If you are considering TMS for depression, cost is often one of the first questions. A full course of TMS involves dozens of in-office sessions, so it is natural to wonder what you will pay and whether your insurance will help.
The good news is that TMS for major depressive disorder is covered by most major insurance plans, including Medicare and TRICARE, when coverage criteria are met. What you actually pay depends on your plan, your deductible and whether your insurer approves treatment in advance. Here is how it works in New Mexico.
What does a course of TMS involve?
A standard NeuroStar TMS course is about 36 sessions. Most people come in five days a week for roughly six weeks, followed by a short taper. Each session takes about 19 to 37 minutes. Because TMS is billed per session, the total cost reflects the whole course rather than a single visit.
Insurers and clinics use three standard billing codes for TMS: 90867 for the first session (which includes mapping the treatment location and measuring your motor threshold), 90868 for each follow-up treatment session, and 90869 when the motor threshold needs to be measured again during the course. If you call your insurer to ask about coverage, having these codes handy can make the conversation easier.
Does insurance cover TMS therapy?
In most cases, yes. According to NeuroStar, more than 300 million people in the U.S. have insurance plans with a coverage policy for TMS (NeuroStar). Coverage is usually for adults with major depressive disorder who have not improved enough with antidepressant medication.
Most plans require prior authorization, which means your insurer reviews your records and approves treatment before you start. Common requirements include:
- A diagnosis of major depressive disorder
- A documented history of antidepressant medications that did not bring enough relief, often two or more
- A baseline score on a standard depression questionnaire, such as the PHQ-9
- In some plans, a trial of talk therapy
Criteria vary from plan to plan, so the details of your policy matter. Once treatment is approved, your share of the cost depends on your deductible, copay or coinsurance, and out-of-pocket maximum.
Does Medicare cover TMS?
Medicare covers TMS for adults with major depressive disorder when medical necessity criteria are met. Medicare Advantage plans must cover the same services as Original Medicare, but they may have their own prior authorization steps and cost-sharing. If you have a Medicare supplement (Medigap) plan, it may help with coinsurance.
Does TRICARE cover TMS?
Yes. TRICARE covers TMS on an outpatient basis for adults with major depressive disorder. TRICARE’s criteria generally include an evaluation by a TRICARE-authorized mental health provider, a baseline PHQ-9 score of 15 or higher within the previous four weeks, and a documented lack of response to at least two antidepressants from different drug classes. New Mexico is in the TRICARE West Region, and prior authorization is required.
Veterans may also be able to access TMS through the VA, including through community care when the VA authorizes treatment outside a VA facility. If you are a veteran, ask your VA care team whether a community care referral for TMS is an option.
What if you have New Mexico Medicaid or another plan?
If you have New Mexico Medicaid (Turquoise Care), coverage for TMS depends on your managed care organization and its prior authorization rules. The same is true for employer and marketplace plans: most cover TMS for depression, but the requirements differ. The fastest way to find out is to ask us to verify your benefits.
What does TMS cost without insurance?
Without insurance, you pay for each session, and a full course of more than 30 sessions adds up. Pricing varies between clinics and by the number of sessions you need. If you do not have coverage, or your plan denies treatment, ask about self-pay pricing and payment options before you begin.
TMS is a medical treatment, so it is often an eligible expense for a health savings account (HSA) or flexible spending account (FSA). Check with your account administrator to confirm.
Questions to ask before you start
- Is TMS for depression covered under my plan, and is prior authorization required?
- What is my deductible, and how much of it have I met this year?
- What is my copay or coinsurance for each TMS session (codes 90867 and 90868)?
- Is there a limit on the number of sessions covered?
- Is Mediterra Mindful Care in network for my plan?
For more questions to bring to your consultation, see questions to ask before starting TMS therapy.
Let us check your coverage
You do not have to sort out insurance on your own. Our team verifies benefits and handles the prior authorization paperwork with your insurer before you start treatment, so you know what to expect before your first session.
Learn more about TMS therapy in Albuquerque, or contact Mediterra Mindful Care and we will check your coverage for you.
