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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.
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.