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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.
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.
PayerOne Plus 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.
PayerPremera Blue Cross CoverageCovered to the same extent as surgical abortions. ReimbursementProviders submit claims using code S0190 for Mifeprex, S0191 for misoprostol and S0199 for all other related services. The drug is reimbursed at AWP +10%. Other

Oregon State Medicaid Information

Oregon Department of Human Services
500 Summer Street, NE, 3rd Floor
Salem, OR 94310-1014
Local: 1-503-945-5772
Toll free: In-State Calls Only 1-800-527-5772
http://oregon.gov/DHS/healthplan/index.shtml

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