| 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 Massachusetts | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed separately at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. | |
| Boston Medical Center Healthnet Plan | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed separately at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. | |
| 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. |
| Consolidated Health Plan | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed separately at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. | |
| Fallon Health Plan | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed separately at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. | |
| 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. |
| Guardian | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed separately at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. | Ob/gyns and family practitioners are covered. |
| Harvard Pilgrim Health Care | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed separately at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. | |
| Health Care Value Management | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed separately at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. | |
| Massachusetts Medicaid (Mass Health) | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed separately at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. | |
| Neighborhood Health Plan | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed separately at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. | |
| Network Health | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed separately at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. | |
| Pioneer | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed separately at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. | |
| Tufts Health Plan | Mifeprex is covered to the same extent as surgical abortions. | Provision of Mifeprex is covered as a bundled rate including office visits and associated supplies with the HCPCS code S0199. The drugs are reimbursed separately at invoice cost using HCPCS code S0190 for Mifeprex and S0191 for misoprostol. |
Massachusetts State Medicaid Information
Office of Health and Human Services of Massachusetts
600 Washington Street
Boston, MA 02111
Toll free: 1-800-325-5231
www.mass.gov/masshealth