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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 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.
Minnesota Medicaid Mifeprex is covered to the same extent as surgical abortions. Minnesota Health Care Programs has conditions under which abortions are covered. A Medical Necessity Statement (DHS-2327 11-98), indicating one of the reasons for the abortion, must be completed and attached to the claim. Use the appropriate abortion diagnosis code: 635.0 - 635.9; 637.0 - 637.9; 69.01, 69.51, and 75.0. Reimbursement for office visits uses E/M codes. The drug is reimbursed as a pass through based on the invoice cost. Use HCPCS code S0190 for Mifeprex. Use HCPCS code S0191 for misoprostol.

Minnesota State Medicaid Information

Department of Human Services of Minnesota
444 Lafayette Road North
St. Paul, MN 55155
Local: 1-651-431-2670
Toll free: 1-800-657-3739
www.dhs.state.mn.us