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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.
PayerBlue Cross and Blue Shield of North Carolina CoverageMifeprex is covered to the same extent as surgical abortions. ReimbursementNo 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. OtherWhen the policy is developed, it will be available on the website at www.bcbsnc.com/providers.
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.
PayerOptimum Choice CoverageMifeprex is covered to the same extent as surgical abortion. ReimbursementOffice visits are covered using regular E&M codes. Providers should use S0190 to be reimbursed for Mifeprex and S0191 to be reimbursed for misoprostol. OtherOb/gyns and family practitioners are covered. However, if the family practitioner is not the patient's primary care physician, there is no coverage.
PayerUnited HealthCare CoverageMifeprex is covered to the same extent as surgical abortions. ReimbursementOffice 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. OtherFamily 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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