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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.
Medi-Cal (California Medicaid) Mifeprex is covered to the same extent as surgical abortions. Medi-Cal covers all abortion services for eligible women. Provision of Mifeprex is covered as a bundled rate, including office visits and associated services and supplies (excluding the drugs), using the local code Z0336. The reimbursement rate for this code is $383.10 for physicians and $402.34 for clinics. The drugs are reimbursed separately using local codes X7724 for Mifeprex and X7726 for misoprostol. The reimbursement rate for Mifeprex is $85.50 and the rate for misoprostol is $1.02. The services included in Z0336 include two visits and two ultrasounds, laboratory studies, urine pregnancy test, and recipient education.
Pacificare Mifeprex is covered to the same extent as surgical abortion. Physicians receive a monthly payment per enrollee that covers all professional services (capitation). All abortion services including provision of Mifeprex are included under the capitation. Some medical groups may provide abortion services internally or they may subcontract with outside providers. For subcontractors, specific payment rates are negotiated with individual medical groups.

California State Medicaid Information

California Department of Health Services
P.O. Box 997413
Sacramento, CA 95899-7413
Local: 1-916-636-1980
www.medi-cal.ca.gov

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