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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.
Blue Cross and Blue Shield of New Mexico Mifeprex is covered to the same extent as surgical abortions. Providers should bill for the drugs using codes J8499, J3490, J4999 or CPT code 99070. Claims are reviewed and paid manually. Office visits and all other services are paid separately. Providers should inform Blue Cross of their intention to provide this service. The drugs will be reimbursed based on the Average Wholesale Price (AWP).
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.
New Mexico Medicaid Mifeprex is covered to the same extent as surgical abortion. Office visits are reimbursed using general office visit codes. Providers should use S0190 for Mifeprex and S0191 for misoprostol. New Mexico Medicaid only covers abortions that are deemed medically necessary.
Presbyterian Mifeprex is covered to the same extent as surgical abortion. Providers should submit claims for Mifeprex and misoprostol using code J8499. Please list "Mifeprex" on the claim next to the J code. Providers should use regular E&M codes for office visits. Both OB/GYNs and family practitioners will be reimbursed.
United Healthcare Mifeprex is covered to the same extent as surgical abortion. Providers should submit claims for Mifeprex using code S0190 and for misoprostol using S0191. Providers should use regular E&M codes for office visits. The drug will be paid at the AWP, or the AWP plus or minus 10%, depending on the provider's contract. Both OB/GYNs and family practitioners will be reimbursed.

New Mexico State Medicaid Information

Department of Human Services of New Mexico
P.O. Box 2348
Sante Fe, NM 87504-2348
Local: 1-505-827-3100
Toll free: 1-888-997-2583
TTY: 1-505-827-3184
Spanish: 1-800-432-6217
www.state.nm.us/hsd/mad/index.html

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