PARTNERSHIP HEALTHPLAN OF CALIFORNIA
POLICY/ PROCEDURE
Policy/Procedure Number: MCUP3050 (previously UP100350)
Policy/Procedure Title: Medical Abortions
Lead Department: Health Services
☒External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Last Review Date: 02/18/2015
Original Date: 01/17/2001
Applies to:
☒ Medi-Cal
☐ Healthy Kids
☐ Employees
Reviewing
Entities:
☒ IQI
☐P&T
☒ QUAC
☐ OPERATIONS
☐ EXECUTIVE
☐ COMPLIANCE
☐ DEPARTMENT
☐ BOARD
☐ COMPLIANCE
☐ FINANCE
☒ PAC
☐ CREDENTIALING
☐ DEPT. DIRECTOR/OFFICER
Approving
Entities:
☐ CEO
☐ COO
Approval Signature: Robert Moore, MD, MPH
Approval Date: 02/18/2015
I.
RELATED POLICIES:
A. MCUG3024 Inpatient Utilization Management
B. MCUP3015 Family Planning By-Pass Services
II.
IMPACTED DEPTS:
A. Health Services
B. Claims
C. Member Services
III.
DEFINITIONS: N/A
IV.
ATTACHMENTS:
A. Patient Agreement Form
B. Sample Letter to Partnership HealthPlan of California from provider
V.
PURPOSE:
To define the guidelines for appropriate management of medical abortions using mifepristone
VI.
POLICY / PROCEDURE:
This policy describes provider, member, and PHC considerations with regard to the medical management of
abortion using mifepristone. This medication, an antiprogestin, has been approved by the FDA for
termination of intrauterine pregnancies of 49 days or less. It is generally used with misoprostol, an E1
prostaglandin analog. Studies have shown that oral mifepristone 600 mg. followed two days later by 400
mcg. of oral misoprostol, leads to complete abortion in 92% to 97% of patients. The primary complications
are vaginal bleeding and crampy abdominal pain, which may be severe. Curettage may be needed to control
bleeding or, after treatment failure, to terminate the pregnancy.
A. Provider Requirements
1. Under Federal law, mifepristone must be provided by, or under the supervision of, a physician who
meets the following qualifications:
a. The prescriber must have the ability to assess the duration of pregnancy accurately.
b. The prescriber must have the ability to diagnose ectopic pregnancies.
c. The prescriber must be able to provide surgical intervention in cases of incomplete abortion or
severe bleeding, or has made arrangements to provide such care through other appropriately
trained and credentialed practitioners, and is able to assure patient access to medical facilities
equipped to provide blood transfusion and resuscitation, if necessary.
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Policy/Procedure Number: MCUP3050 (previously
UP100350)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Last Review Date: 02/18/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Medical Abortions
Original Date: 01/17/2001
☒ Medi-Cal
Applies to:
2.
3.
4.
5.
6.
d. The prescriber has read and understood the prescribing information on mifepristone. The
prescribing information is available by calling the toll free number, 1-877-432-7596, or
accessing the manufacturer’s website at www.earlyoptionpill.com
Providers of medical abortions must be available to patients receiving this care after office hours and
must have made arrangements with a suitable facility when emergency surgical intervention is
necessary, including after office hours.
The prescriber must provide each patient with a Mifepristone Medication Guide. The prescriber
must fully explain the procedure to each patient, provide her with a copy of the Mifepristone
Medication Guide and Patient Agreement form (see Attachment A), give her an opportunity to read,
discuss, then obtain her signature on the Patient Agreement form and the prescriber must sign it.
In addition, the prescriber should emphasize to the patient that follow-up at day 3 and day 14 after
use of mifepristone is very important to confirm that a complete termination of pregnancy has
occurred and that there have been no complications. The prescriber must notify the manufacturer in
writing as discussed in the Package Insert under the heading Dosage and Administration in the event
of an on-going pregnancy which is not terminated subsequent to the conclusion of the treatment
procedure. While serious adverse events associated with the use of mifepristone are rare, the
prescriber must report any hospitalization, transfusion, or other serious event to the manufacturer,
identifying the patient solely by package serial number to ensure patient confidentiality.
The provider must keep on file a signed Patient Agreement Form.
The provider must submit a treatment authorization form (TAR) for services requiring
hospitalization arising as a consequence of a medical abortion.
B. Patient Requirements
1. The patient must read carefully and understand the Mifepristone Medication Guide, which will help
in understanding how the treatment works.
2. The patient must sign the Patient Agreement Form.
3. The patient must agree to see her provider on Day 3 and Day 14 after receiving the medication.
C. PHC Requirements
1. PHC will reimburse Medi-Cal providers for the service.
2. PHC does not require prior authorization or medical justification for medical abortion services, but
does require authorization for inpatient hospital services for complications arising from medical
abortions when such services are medically necessary.
3. Medical Abortions are considered sensitive services and as such are provided to PHC members in a
timely manner through the member’s PCP (if appropriately qualified), OB/Gyn specialist, or
providers of family planning bypass services.
4. PHC monitors the quality of medical abortion services provided by physicians who are Plan
providers through member issues or the Plan’s PQI process.
VII.
REFERENCES:
N/A
VIII.
DISTRIBUTION:
A. PHC Provider Manual
B. OB/Gyn Providers
C. PHC Department Directors
IX.
POSITION RESPONSIBLE FOR IMPLEMENTING PROCEDURE: Senior Director, Health Services
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Policy/Procedure Number: MCUP3050 (previously
UP100350)
Lead Department: Health Services
☒ External Policy
☐ Internal Policy
Next Review Date: 02/18/2016
Last Review Date: 02/18/2015
☐ Healthy Kids
☐ Employees
Policy/Procedure Title: Medical Abortions
Original Date: 01/17/2001
Applies to:
X.
☒ Medi-Cal
REVISION DATES:
02/14/01 (Physician Advisory Committee); 09/19/01; 10/16/02, 10/20/04; 10/19/05, 10/18/06, 08/20/08;
11/28/12; 02/18/15
PREVIOUSLY APPLIED TO:
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