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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 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.
Optimum Choice Mifeprex is covered to the same extent as surgical abortion. Office visits are covered using regular E&M codes. Providers should use S0190 to be reimbursed for Mifeprex and S0191 to be reimbursed for misoprostol. Ob/gyns and family practitioners are covered. However, if the family practitioner is not the patient's primary care physician, there is no coverage.
West Virginia Medicaid Effective 1/1/02, Mifeprex is covered to the same extent as surgical termination. Providers should submit claims using code S0190 for Mifeprex, S0191 for misoprostol and S0199 for the procedure (counseling, office visits, ultrasound, etc). The drug will be paid at the invoice cost and the procedure will be paid at a global rate ($309.95). The global rate includes all related laboratory services and ultrasounds. Services must be provided in a manner consistent with the FDA requirements for patient notification and follow-up. The claim form must be accompanied by an executed physician certification for pregnancy form. Inquiries related to the West Virginia Policy should be directed to Consultec, Inc., Provider Service Unit, P.O. Box 2002, Charleston, West Virginia 25327-2002; (304) 345-0101 or toll-free at 1-800-433-3019 (for in-state providers).

West Virginia State Medicaid Information

West Virginia Department of Health & Human Resources
350 Capitol Street, Room 251
Charleston, WV 25301-3709
Local: 1-304-558-1700
www.wvdhhr.org/bms/

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