| 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 Illinois | Mifeprex is covered to the same extent as surgical abortions. | Reimbursement for the office visits uses E/M codes. The drugs are reimbursed using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. All other services are reimbursed separately, if medically necessary. | The reimbursement rate for Mifeprex is based on the Average Wholesale Price (AWP). |
| 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. |
| Illinois Medicaid | Mifeprex is covered to the same extent as surgical abortions. State Medicaid funds are available in cases where the health or life of the mother is endangered, rape, or incest. | Physicians are paid a global rate of $125 for the 3 office visits. The physician may bill after the first visit. The codes for the visits are: W7579 (health endangered), W7576 (life endangered), W7577 (rape) and W7578 (incest). Mifeprex will be reimbursed at $324 and should be billed using HCPCS code S0190. Misoprostol should be billed using HCPCS code S0191. Any other procedures or tests (such as ultrasound) should be billed using the applicable CPT code and will be reimbursed using the normal fee schedule. | Click here for a link to the Illinois Medical Assistance Program Provider Bulletin dated 4/18/01, “Coverage of the Drug Mifepristone for Termination of Pregnancy”. Coverage is retroactive to September 28th, 2000. |
| John Deere Health | Mifeprex is covered to the same extent as surgical abortions. | Mifeprex should be submitted using code S0190 and misoprostol using code S0191. Regular E&M codes should be used for office visits. | Family practitioners are covered. If a patient obtains Mifeprex from a family practitioner who is not her PCP, a referral is needed if the doctor is out of network. If the doctor is in-network, a referral is needed if the patient is in the Select Plan. If the patient is in the Choice Plan, and the doctor is in-network, no referral is needed. |
| UnitedHealthcare of the Midwest | Mifeprex is covered to the same extent as surgical abortions. | Reimbursement for the office visits uses E/M codes. The drugs are reimbursed using code J3490. All other services are reimbursed separately, if medically necessary. | The reimbursement rate for Mifeprex varies based on the contract. |
Illinois State Medicaid Information
Illinois Department of Healthcare and Family Services
201 South Grand Avenue
East Springfield, IL 62763
Local: 1-217-782-1200
Toll free: 1-866-468-7543
Spanish: 1-217-785-8036