CurrentBlue Cross Blue Shield - Rhode IslandPolicy N/A

Termination of Pregnancy (Abortion) Coverage Policy

BCBSRI coverage policy for termination of pregnancy (surgical and medical), outlining when terminations are covered for Medicare Advantage and commercial products and related billing instructions; applies to providers billing Blue Cross & Blue Shield of Rhode Island.

Policy Summary

PayerBlue Cross Blue Shield - Rhode Island

PolicyTermination of Pregnancy (Abortion) Coverage Policy

Policy CodePolicy N/A

Change TypeNo material change

Effective DateOct 1, 1998

Next Review DateN/A

Key ActionVerify member benefits in the Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to confirm applicable termination coverage.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

No prior authorizationPrior authorization requirement

Rape/incestCoverage condition

Life‑threateningCoverage condition

G7Billing modifier

MifepristoneMedication referenced

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria for Termination of Pregnancy

Covered indications

Termination of pregnancy is covered in the following situations (effective on or after October 1, 1998):

Medicare Advantage coverage

1: Pregnancy is the result of an act of rape or incest.
2: A pregnant person has a physician‑certified physical disorder, physical injury, or physical illness (including a life‑endangering physical condition caused by the pregnancy) that places the pregnant person in danger of death unless an abortion is performed.

Commercial products coverage: Most commercial and individual plans cover termination of pregnancy; HOWEVER, some subscriber agreements restrict coverage to cases of rape, incest, or a life‑threatening condition to the pregnant person — verify the member's Subscriber Agreement/Benefit Booklet for applicable exceptions.

From Commercial Products section

Benefits for termination of pregnancy may vary between subscriber groups. Refer to the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to determine whether termination services are covered for that plan. Some individual or group subscriber agreements restrict coverage to terminations that are the result of rape or incest, or that are necessary because the pregnancy poses a life‑threatening physical condition to the pregnant person; services outside those subscriber agreement exceptions may be denied.

Medical Criteria: Not applicable.

Coding and Billing

Required modifier for covered terminationsModifier

G7	Modifier G7 — used to indicate termination of pregnancy due to rape, incest, or life‑threatening condition

Mifeprex gestational age limit

Gestational age limitMifeprex (mifepristone) indicated for medical termination through 49 days from the first day of the patient’s last menstrual period

Medication pairingMifeprex is used together with misoprostol for medical termination

Mechanism noteMifeprex blocks progesterone, which prepares the uterine lining and helps maintain pregnancy

Provider Actions and Requirements

Prior Authorization

Prior authorization is not required.

Note

Verify member benefits

Providers should verify member coverage before scheduling or providing termination of pregnancy services. Use the member's Benefit Booklet, Evidence of Coverage, or Subscriber Agreement to confirm whether maternity, termination, office visit, and drug benefits apply.

Denial Risk

Plan-specific coverage exceptions

Coverage varies by product and subscriber agreement. Most commercial and individual plans cover termination of pregnancy, but some plans limit coverage to cases of rape, incest, or when the pregnancy threatens the member's life. For medical terminations, drug costs are processed under the member's physician‑administered drug benefit and office visits are processed under the member's office visit benefit. Some plans may require PCP referral for specialty benefits — confirm referral requirements in the subscriber agreement.

Background

Termination of pregnancy (also known as abortion) may be accomplished by surgical or medical methods. Surgical procedures include techniques such as dilation and suction curettage, dilation and evacuation, labor induction, and other operative approaches. Medical termination uses abortifacient medications — for example, mifepristone given with misoprostol — with specific product labeling noting use through 49 days from the first day of the last menstrual period for Mifeprex.

Definitions

Medical termination

DefinitionMedical termination: termination accomplished with abortifacient medications (e.g., mifepristone [Mifeprex] used with misoprostol)

Example medicationsMifeprex (mifepristone) plus misoprostol

Availability noteMifeprex and misoprostol are not available through retail pharmacies per the policy note

Surgical termination

DefinitionSurgical termination: termination accomplished via procedures such as dilatation and suction curettage, dilatation and evacuation, labor induction, hysterotomy, intact dilatation and extraction, and includes multi‑fetal reduction

Example procedureDilatation and suction curettage (D&C)