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Health plans are drawing on existing benefits language to make coverage decisions about mifepristone, the newly approved abortion pill. The pill is administered directly by prescribers, so it is not treated as a pharmacy benefit. Among others, PacifiCare, Aetna U.S. Healthcare, Cigna, and United HealthCare cover mifepristone (also known as RU-486) as a standard medical benefit — the same as surgical abortion. Where family planning services are a covered benefit, mifepristone will be covered as an in-office procedure under that category, a pharmacy benefit. PacifiCare, Aetna U.S. Healthcare, Cigna, and United Healthcare, among others, cover mifepristone (also known as RU-486) as a standard medical benefit — as with surgical abortion. Where family planning services are covered, mifepristone will be considered an in-office procedure.
While projections show medical abortions may replace more than 30 percent of surgical abortions, the financial impact on health plans is expected to be negligible, because mifepristone's cost is comparable to that of surgical abortion.
Sam Ho, M.D., vice president and corporate medical director for PacifiCare, says its coverage decision was based on an evaluation of scientific literature, followed by a determination of which of its plans cover abortion. Because there is flexibility in the administration of mifepristone, PacifiCare developed clinical guidelines for use and dosage.
The difference between mifepristone and some other drugs, in terms of coverage decisions, involves splitting medical necessity from covered benefits. "Treatment of male impotence is a covered benefit, but much use of Viagra isn't truly medically necessary," Ho says by way of example. "So to provide Viagra when appropriate, we have guidelines for its use."
The Department of Health and Human Services is still determining whether Medicaid programs should cover mifepristone — and the implications may be huge, according to Daniel C. Malone, Ph.D., R.Ph., assistant professor at the University of Arizona College of Pharmacy. "This will be a sensitive subject for many states. It may reverse their portfolio of covered products in terms of reproductive medications."
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