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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 North Carolina Mifeprex is covered to the same extent as surgical abortions. No formal guidelines have been issued yet on reimbursement or claims submission. During the interim, providers should submit using J8499. The claims will be reviewed and paid manually. When the policy is developed, it will be available on the website at www.bcbsnc.com/providers.
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.
United HealthCare Mifeprex is covered to the same extent as surgical abortions. Office visits are reimbursed using regular E&M codes. Mifeprex and misoprostol should be submitted using J3490. The J3490 code should be accompanied by a description of the medication. Family practitioners and ob/gyns are covered. No referral is needed if the family practitioner is not the patient’s primary care physician. United HealthCare will not reimburse if Mifeprex is given to someone whose pregnancy is past 49 days LMP.

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