Choose Another State
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 Michigan Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. Enter type-of-service code 9, other medical service, in field 24C, Type of Service. Enter all 3 procedure codes, S0190, S0191, and S0199 in field 24D, CPT/HCPCS. Family practitioners are covered, but if the family practitioner is not the patient's regular PCP, a referral is needed. There is no reimbursement if the pregnancy is past 49 days LMP.
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.
Health Plus of Michigan Mifeprex is covered to the same extent as surgical abortions. Office visits are reimbursed using regular E&M codes. Providers should use J3490 for Mifeprex and misoprostol. The J3490 code must be accompanied by a description of the medication, dosage, and NDC number. Family practitioners are covered. A referral is needed if the family practitioner is not the patient’s primary care physician.