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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.
Anthem Blue Cross and Blue Shield Mifeprex is covered to the same extent as surgical abortions. Mifeprex should be submitted for reimbursement using code S0190 and misoprostol using code S0191. Office visits and associated supplies are covered as a bundled rate using code S0199. Family practitioners and ob/gyns are covered.
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.
PacifiCare Mifeprex is covered to the same extent as surgical abortion. Mifeprex is to be submitted using S0190 and misoprostol is to be submitted using S0191. Regular E&M codes should be used for office visits. Prior authorization is needed. Family practitioners are covered. A referral is needed if the family practitioner is not the patient’s PCP.
Rocky Mountain Plans Covered to the same extent as surgical abortions. Providers must call Customer Relations or their Provider Reps in order to obtain the proper codes. Ob/gyns and family practitioners are covered. No referral is needed if the family practitioner is not the patient’s primary care physician.
UnitedHealthcare of Colorado Mifeprex is covered to the same extent as surgical abortions. Providers should submit claims for Mifeprex using code S0190 and for misoprostol using S0191. The drugs will be paid at the AWP, or the AWP plus or minus 10% depending on the provider's contract. Reimbursement for the office visits uses E/M codes. Both OB/GYNs and family practitioners will be reimbursed. No referral is needed if a patient obtains Mifeprex from a family practitioner who is not her PCP.

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