21st Century Health & Benefits

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.

Ob/gyns and family practitioners are covered. No referrals for FPs are needed.

Aetna US Healthcare

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.

AmeriHealth

Mifeprex is covered to the same extent as surgical abortion.

Associated office visits and supplies are covered as a bundled rate using code S0199. Providers should submit claims for Mifeprex using code S0190 and for misoprostol using S0191. Mifeprex will be reimbursed at the AWP minus 10%.

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

Blue Cross of Northeastern Pennsylvania

Mifeprex is covered to the same extent as surgical abortions.

Reimbursement for the office visits uses E/M codes. The drugs are reimbursed using CPT code 59899 (unlisted procedure, maternity care and delivery). All other services are reimbursed separately, if medically necessary.

Blue Cross/Blue Shield of Western Pennsylvania

Mifeprex is covered to the same extent as surgical abortion, depending on the member's contract.

Providers should submit claims for Mifeprex using code S0190 and for misoprostol using S0191. The drugs will be paid based on the AWP. The office visits and other related services should be billed using S0199. Coverage for the medication and procedure falls under the maternity benefit.

CIGNA

Mifeprex is covered to the same extent as surgical abortion.

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.

Healthnet

Mifeprex is covered to the same extent as surgical abortion.

Providers should submit claims for Mifeprex using code J8499. The claim form must include the name of the drug, the NDC number and the dosage. Providers should use regular E&M codes for office visits.

Healthnet will reimburse family practitioners. Under the Passport plan, if a family practitioner is providing Mifeprex, but is not the primary care provider for the patient, a referral (either prescription or telephone) will be needed. Under the Charter plan, no such referral is needed.

Highmark Blue Cross/Blue Shield

Mifeprex is covered to the same extent as surgical abortion.

Mifeprex should be submitted using code S0190 and misoprostol using code S0191. Office visits and associated supplies are covered as a bundled rate using code S0199.

Family practitioners are covered. A referral is needed if a patient obtains Mifeprex from a family practitioner who is not her PCP. If claim submission is by paper, no narrative is needed. If the submission is electronic, the S0199 code must be accompanied by a description of what the S code is for.

Keystone Health Plan

Mifeprex is covered to the same extent as surgical abortion.

Mifeprex is submitted using code S0190 and misoprostol using code S0191. Office visits and associated supplies are covered as a bundled rate using code S0199.

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

Oxford

Mifeprex is covered to the same extent as surgical abortions.

Mifeprex is covered using code S0199 for the procedure, S0190 for Mifeprex and S0191 for Misoprostol. Primary care physicians, including family practitioners, can bill for the service. The mifeprex claim should include the NDC# 64875-001-03. Office visits, ultrasound, and other ancillary services are billed separately and are reimbursed based on the regular fee schedule.

Pennsylvania Medicaid

Mifeprex is covered to the same extent as surgical abortion.

Office visits should be submitted using regular E&M codes. Mifeprex should be submitted using NDC #64875-0001-03. Misoprostol should be submitted using NDC #00025-1451-20/34-60 for 100 mcg tablets and NDC #00025-1451-31/34/60 for 200 mcg tablets.

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

Personal Choice

Mifeprex is covered to the same extent as surgical abortion.

Mifeprex should be submitted using code S0190 and misoprostol using code S0191. Office visits and associated supplies are covered as a bundled rate using code S0199.

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