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Illinois

Payer Coverage Reimbursement Other

Aetna US Healthcare

Mifeprex is covered to the same extent as surgical abortions.

Reimbursement for a patient's non-primary care physician uses E/M codes for office visits; the drug is reimbursed using code J3490 and is paid based on the physician's invoice cost. If the patient's primary care physician is providing Mifeprex and s/he is capitated, the office visits are under the capitation. The drug cost is reimbursed separately based on the invoice cost.

OB/GYNS will not need a referral to provide Mifeprex to their patients. If an internist or family practice physician is providing Mifeprex but s/he is not the primary care provider for the patient, a referral will be needed.

Blue Cross and Blue Shield of Illinois

Mifeprex is covered to the same extent as surgical abortions.

Reimbursement for the office visits uses E/M codes. The drugs are reimbursed using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. All other services are reimbursed separately, if medically necessary.

The reimbursement rate for Mifeprex is based on the Average Wholesale Price (AWP).

CIGNA

Mifeprex is covered to the same extent as surgical abortions.

Mifeprex should be submitted using S0190 and misoprostol using S0191. Regular E&M codes should be used for office visits.

Family practitioners are covered. A referral is needed if a patient obtains Mifeprex from a family practitioner who is not her PCP.

Great-West/One Health Plan

Mifeprex is covered to the same extent as surgical abortions.

Office visits are reimbursed using regular E&M codes. Providers should use S0190 for Mifeprex and S0191 for misoprostol.

Family practitioners are covered. A referral is needed if the family practitioner is not the patient’s primary care physician.

Illinois Medicaid

Mifeprex is covered to the same extent as surgical abortions. State Medicaid funds are available in cases where the health or life of the mother is endangered, rape, or incest.

Physicians are paid a global rate of $125 for the 3 office visits. The physician may bill after the first visit. The codes for the visits are: W7579 (health endangered), W7576 (life endangered), W7577 (rape) and W7578 (incest). Mifeprex will be reimbursed at $324 and should be billed using HCPCS code S0190. Misoprostol should be billed using HCPCS code S0191. Any other procedures or tests (such as ultrasound) should be billed using the applicable CPT code and will be reimbursed using the normal fee schedule.

Click here for a link to the Illinois Medical Assistance Program Provider Bulletin dated 4/18/01, “Coverage of the Drug Mifepristone for Termination of Pregnancy”. Coverage is retroactive to September 28th, 2000.

John Deere Health

Mifeprex is covered to the same extent as surgical abortions.

Mifeprex should be submitted using code S0190 and misoprostol using code S0191. Regular E&M codes should be used for office visits.

Family practitioners are covered. If a patient obtains Mifeprex from a family practitioner who is not her PCP, a referral is needed if the doctor is out of network. If the doctor is in-network, a referral is needed if the patient is in the Select Plan. If the patient is in the Choice Plan, and the doctor is in-network, no referral is needed.

UnitedHealthcare of the Midwest

Mifeprex is covered to the same extent as surgical abortions.

Reimbursement for the office visits uses E/M codes. The drugs are reimbursed using code J3490. All other services are reimbursed separately, if medically necessary.

The reimbursement rate for Mifeprex varies based on the contract.

State Medicaid Information

Illinois Department of Healthcare and Family Services
201 South Grand Avenue
East Springfield, IL 62763
Local: 1-217-782-1200
Toll free: 1-866-468-7543
Spanish: 1-217-785-8036

www.hfs.illinois.gov/

IMPORTANT SAFETY INFORMATION

Although cramping and bleeding are an expected part of ending a pregnancy, rarely, serious and potentially life-threatening bleeding, infections, or other problems can occur following a miscarriage, surgical abortion, medical abortion, or childbirth. Prompt medical attention is needed in these circumstances. Serious infection has resulted in death in a very small number of cases; in most of these cases misoprostol was used in the vagina. There is no information that use of Mifeprex and misoprostol caused these deaths. If you have any questions, concerns, or problems, or if you are worried about any side effects or symptoms, you should contact your provider.

Be sure to contact your provider promptly if you have any of the following:

Heavy Bleeding. Contact your provider right away if you bleed enough to soak through two thick full-size sanitary pads per hour for two consecutive hours or if you are concerned about heavy bleeding. In about 1 out of 100 women, bleeding can be so heavy that it requires a surgical procedure (surgical abortion/D&C) to stop it.

Abdominal Pain or “Feeling Sick”. If you have abdominal pain or discomfort, or you are “feeling sick”, including weakness, nausea, vomiting, or diarrhea, with or without fever, more than 24 hours after taking misoprostol, you should contact your provider without delay. These symptoms may be a sign of a serious infection or another problem (including an ectopic pregnancy, a pregnancy outside the womb).

Fever. In the days after treatment, if you have a fever of 100.4°F or higher that lasts for more than 4 hours, you should contact your provider right away. Fever may be a symptom of a serious infection or another problem (including an ectopic pregnancy).

Take your MEDICATION GUIDE with you. When you visit an emergency room or a provider who did not give you your Mifeprex, you should give them your MEDICATION GUIDE so that they understand that you are having a medical abortion with Mifeprex.

Mifeprex* is a registered trademark
of Danco Laboratories, LLC
1-877-4 Early Option
1-877-432-7596
info@earlyoptionpill.com
FDA approved since 2000.
A safe and effective non-surgical option for ending early pregnancy.