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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 of Oklahoma CoverageMifeprex is covered to the same extent as surgical abortion: only for medical necessity. ReimbursementWhen it is deemed medically necessary, Mifeprex would be reimbursed at invoice cost. Office visits and ancillary expenses would be reimbursed according to fee schedule. OtherNone of the plans cover elective abortion, but do cover medical necessity. Claims would need to be reviewed on an individual basis.
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.
PayerPreferred Health Systems CoverageMifeprex is covered to the same extent as surgical abortion. ReimbursementOffice visits are reimbursed using regular E&M codes. Providers should use S0190 for Mifeprex and S0191 for misoprostol. OtherOb/gyns and family practitioners are covered. In the HMO plan, a family practitioner cannot refer to another family practitioner.

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