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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.
Blue Cross and Blue Shield of Rhode Island Mifeprex is covered to the same extent as surgical abortions. Provision of Mifeprex is covered as a bundled rate for the office visits and the drugs using a modified NDC code, 64875001. The reimbursement rate for the Mifeprex regimen is based on the specific contract and provider. Ultrasounds are reimbursed separately, if medically necessary.
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.
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.