| Payer | Coverage | Reimbursement | Other |
|---|---|---|---|
| PayerAetna US Healthcare | CoverageMifeprex is covered to the same extent as surgical abortions. | ReimbursementReimbursement 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. | OtherOB/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. |
| PayerAnthem Blue Cross and Blue Shield | CoverageMifeprex is covered to the same extent as surgical abortions. | ReimbursementMifeprex 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. | OtherFamily practitioners and ob/gyns are covered. |
| PayerCIGNA | CoverageMifeprex is covered to the same extent as surgical abortion. | ReimbursementMifeprex should be submitted using S0190 and misoprostol using S0191. Regular E&M codes should be used for office visits. | OtherFamily practitioners are covered. A referral is needed if a patient obtains Mifeprex from a family practitioner who is not her PCP. |
| PayerGreat-West/One Health Plan | CoverageMifeprex is covered to the same extent as surgical abortions. | ReimbursementOffice visits are reimbursed using regular E&M codes. Providers should use S0190 for Mifeprex and S0191 for misoprostol. | OtherFamily practitioners are covered. A referral is needed if the family practitioner is not the patient’s primary care physician. |
| PayerHealthnet | CoverageMifeprex is covered to the same extent as surgical abortion. | ReimbursementProviders should submit claims for Mifeprex using code J8499. The claim form must include the name of the drug, the NDC number, and the dosage. Providers should use regular E&M codes for office visits. | OtherHealthnet will reimburse family practitioners. Under the Passport plan, if a family practitioner is providing Mifeprex, but is not the primary care provider for the patient, a referral (either prescription or telephone) will be needed. Under the Charter plan, no such referral is needed. |
| PayerMedicaid | CoverageMifeprex is covered to the same extent as surgical abortion. | ReimbursementProviders should submit claims for Mifeprex using code S0190 and for misoprostol using S01091. The office visits and other related services should be billed using S0199. The drugs will be paid at the AWP minus 5%. | OtherFamily practitioners are covered. No referral is needed if the family practitioner is not the patient's primary care physician. |
| PayerMedSpan Health Options | CoverageMifeprex is covered to the same extent as surgical abortion. | ReimbursementClaims are to be submitted using either J3490, J8499, or CPT code 99070. Ultrasounds are billed separately. | OtherOb/gyns and family practitioners are covered. No referral is needed if the family practitioner is not the patient’s primary care physician. |
| PayerOxford | CoverageMifeprex is covered to the same extent as surgical abortions. | ReimbursementMifeprex 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. | Other |
| PayerUnited HealthCare | CoverageMifeprex is covered to the same extent as surgical abortion. | ReimbursementOffice visits should be billed using normal E&M codes and are paid at regular office visit rates. Providers should submit claims for Mifeprex using code J8499. All other services (i.e., ultrasounds) can be submitted separately and will be paid according to the normal fee-for-service rates. | Other |
Connecticut State Medicaid Information
Department of Social Services of Connecticut
25 Sigourney Street
Hartford, CT 06106-5033
Local: 1-860-424-4908
Toll free: In-State Calls Only 1-800-842-1508
www.dss.state.ct.us