Prior authorization request form Form

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 1 (401) 274-4848 WWW.BCBSRI.COM EFFECTIVE DATE: 10|01|1998 POLICY LAST UPDATED: 06|18|2019 OVERVIEW This document describes the Blue Cross & Blue Shield of Rhode Island (“BCBSRI”) policy for termination of pregnancy, including in instances of rape, incest, threat to the pregnant person’s life, and all other terminations.
MEDICAL CRITERIA Not applicable PRIOR AUTHORIZATION Prior authorization is not required. POLICY STATEMENT Medicare Advantage Products Effective for services furnished on or after October 1, 1998 termination of a pregnancy is covered in the following situations:

1. If the pregnancy is the result of an act of rape or incest; or
2. In the case where a pregnant person suffers from a physical disorder, physical injury, or physical illness, including a life-endangering physical condition caused by, or arising from the pregnancy itself, that would, as certified by a physician, place the pregnant person in danger of death unless an abortion is performed. Medical termination: The drug used is processed according to the member’s physician administered drug benefit, the office visit is processed according to the member’s office visit coverage benefit. Commercial Products Most accounts and individual plans cover the termination of a pregnancy; HOWEVER, there are exceptions. Subscriber Agreements should be used to verify members’ specific coverage. For some individual or group plans the coverage is restricted to cases of rape, incest, or a life-threatening condition to the pregnant person. Medical termination: The drug used is processed according to the member’s physician administered drug benefit, the office visit is processed according to the member’s office visit coverage benefit. Termination of pregnancy does not require a PCP referral for the services to be covered at the maximum specialty care benefit in those plans that normally require a referral.
   COVERAGE Benefits may vary between groups. Please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement for applicable maternity services, office visits and/or related contract exclusion benefits/coverage. BACKGROUND Termination of pregnancy (also known as abortion) can be either surgical or medical. Surgical terminations may be carried out utilizing a dilatation and suction curettage procedure, a dilatation and evacuation procedure, labor induction, saline infusion, hysterotomy, or intact dilatation and extraction, and includes Payment Policy | Termination of Pregnancy

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 2 (401) 274-4848 WWW.BCBSRI.COM

multi-fetal reduction abortions. Medical terminations are accomplished with abortifacient medications such as Mifeprex (Mifepristone).

Special Information Pertaining to Mifeprex
Mifeprex is an abortifacient, indicated for the medical termination of intrauterine pregnancy through 49 days from the first day of the patient’s last menstrual period. Mifeprex blocks progesterone, a naturally produced hormone that prepares the lining of the uterus for a fertilized egg and helps maintain pregnancy. Mifeprex is used together with another medication called misoprostol.

Mifeprex and misoprostol are NOT available through retail pharmacies.

Emergency Contraception (EC) Also known as backup birth control and morning after pill, emergency contraception is not considered an abortifacient. EC is available at pharmacies under the brand names Plan B and Next Choice. See the Contraceptive Drugs and Devices Mandate policy for further information.

Dobbs vs. Jackson’s Women Health Organization Due to the Supreme Court ruling in June 2022, the federal right to an abortion is no longer guaranteed. In Rhode Island and other New England states, abortions continue to be legal under state law. However, prohibitions are likely to be passed in a number of other states. Some BCBSRI plans may provide travel expenses if access to abortion is limited or not available in the member’s state of residence. For questions about a specific plan, please refer to the appropriate Benefit Booklet, Evidence of Coverage or Subscriber Agreement, or check with Customer Service or your employer.

CODING Based on services provided.

Medicare Advantage Plans and Commercial Products Modifier G7 To ensure correct claims processing, Termination of Pregnancy (TOP) due to rape or incest, or a pregnancy certified by a physician as a life-threatening condition, must be filed with modifier G7 appended.

RELATED POLICIES Contraceptive Drugs and Devices Mandate

PUBLISHED Provider Update, February 2023 Provider Update, August, 2019 Provider Update, April 2018 Provider Update, March 2017 Provider Update, March 2016 Provider Update, July 2015

REFERENCES

1. Mifeprex/(Mifepristone) Information: http://www.fda.gov/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/uc m111323.htm
2. Abortion. (For Informational purposes only). Retrived on September 28, 2007 from the Medline Plus, US National Library of Medicine and the National Institutes of Health website: http://www.nlm.nih.gov/medlineplus/ency/article/002912.htm

500 EXCHANGE STREET, PROVIDENCE, RI 02903-2699 MEDICAL COVERAGE POLICY | 3 (401) 274-4848 WWW.BCBSRI.COM

3. TITLE 23. Health and Safety. CHAPTER 23-4.7. Informed Consent for Abortion. SECTION 23-4.7-1. Retrieved from RI General Assembly website: http://www.rilin.state.ri.us/statutes/title23/23%2D4.7/23%2D4.7%2D1.htm

4. Schaff, E., et.al. (2000).Vaginal Misoprostol Administered 1,2 0r 3 Days After MIfepristone for Early Medical Abortion. Journal of American Medical Association,October 18, 2000. Vol. 284, No. 15:1948-53. Retrieved on September 28, 2007 from JAMA website:
   http://jama.ama- assn.org/cgi/reprint/284/15/1948?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext= abortion&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT

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   This medical policy is made available to you for informational purposes only. It is not a guarantee of payment or a substitute for your medical judgment in the treatment of your patients. Benefits and eligibility are determined by the member's subscriber agreement or member certificate and/or the employer agreement, and those documents will supersede the provisions of this medical policy. For information on member-specific benefits, call the provider call center. If you provide services to a member which are determined to not be medically necessary (or in some cases medically necessary services which are non-covered benefits), you may not charge the member for the services unless you have informed the member and they have agreed in writing in advance to continue with the treatment at their own expense. Please refer to your participation agreement(s) for the applicable provisions. This policy is current at the time of publication; however, medical practices, technology, and knowledge are constantly changing. BCBSRI reserves the right to review and revise this policy for any reason and at any time, with or without notice. Blue Cross & Blue Shield of Rhode Island is an independent licensee of the Blue Cross and Blue Shield Association. CLICK THE ENVELOPE ICON BELOW TO SUBMIT COMMENTS