CurrentUnitedHealthcarePolicy N/A

Mifeprex (mifepristone) 200 mg coverage — pharmacy authorization when plan benefit variations apply

Defines UnitedHealthcare Pharmacy coverage and authorization rules for Mifeprex 200 mg and generic mifepristone 200 mg when plan benefit variations apply; affects providers and pharmacies dispensing under UnitedHealthcare pharmacy benefits and members whose plans alter standard coverage.

Policy Summary

PayerUnitedHealthcare

PolicyMifeprex (mifepristone) 200 mg coverage — pharmacy authorization when plan benefit variations apply

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJul 1, 2025

Next Review DateApr 1, 2025

Key ActionObtain prior authorization for Mifeprex 200 mg or generic mifepristone 200 mg when plan benefit documents indicate variations from standard coverage; authorization is issued for one month.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

7/1/2025policy effective date

1 monthauthorization duration

Jan 3, 2023REMS update

listedP&T reviews

Coverage Criteria

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Initial Authorization

Approved when ALL of the following are met:

Approval criteria: Medication is Mifeprex 200 mg or generic mifepristone 200 mg

Approval criteria: Treatment is consistent with services covered by the patient's medical benefit plan (refer to the member's medical benefit plan document or contact provider services for covered/excluded termination of pregnancy services)

Approval criteria: Plan-specific variation requires pharmacy program authorization

Authorization will be issued for 1 month

Coverage is limited to items and services that are consistent with the member's medical benefit plan. Providers must consult the member's medical benefit plan document or contact Provider Services for details about covered and excluded termination of pregnancy services, as coverage may vary by plan.

Provider Actions and Authorization

Prior Authorization

Authorization requirement and duration

Mifeprex 200 mg and generic mifepristone 200 mg require prior authorization when plan benefit variations to standard coverage are present. Authorization will be issued for 1 month. Treatment must be consistent with services covered by the member's medical benefit plan; providers should reference the member's medical benefit details (for example, the member's medical benefit plan document, provider services at 1-888-842-3210, or the provider portal at www.uhcprovider.com).

Authorization duration: 1 month
Provider resources: member's medical benefit plan document; Provider Services 1-888-842-3210; www.uhcprovider.com

Note

Use of automated prior-authorization logic

Initial and re-authorization decisions may be based on automated review of prior claim and medication history, diagnosis codes (ICD-10), and claim logic. Use of automated prior-authorization logic and re-approval processes varies by program and therapeutic class.

Decisions may rely solely on previous claims/medication history and diagnosis codes
Automated processes vary by program/therapeutic class

Denial Risk

Automated approval/denial processes

Authorization may be denied when automated approval logic, previous claim/medication history, or diagnosis/claim logic do not support approval. Providers should ensure documentation and claims reflect medical benefit coverage and appropriate diagnosis codes to reduce denial risk.

Denial triggers include: automated logic not supporting approval; absence of supporting prior claims/medication history; diagnosis/claim logic inconsistent with coverage

Step	Requirement
1	Authorization and re-authorization decisions may be based on prior claim/medication history and diagnosis codes using automated logic; use of automated approval and re-approval processes varies by program and/or therapeutic class.

Site of Care / Dispensing

Note

Dispensing allowed from certified retail and mail‑order pharmacies

Dispensing is permitted from certified retail and mail‑order pharmacies in accordance with the REMS revision effective January 3, 2023.

REMS revised Jan 3, 2023 to allow certified retail and mail-order pharmacy dispensing

Definitions

REMS — definition and recent change

TermRisk Evaluation and Mitigation Strategy (REMS)

REMS revision dateEffective January 3, 2023

What changedREMS revised to permit dispensing of Mifeprex (mifepristone) by certified retail and mail‑order pharmacies

Previous restrictionPreviously available only when ordered, prescribed, and dispensed by or under the supervision of a healthcare provider

Policy contextChange informs coverage determinations for Mifeprex 200 mg and generic mifepristone 200 mg when plan benefit documents impose variations to UnitedHealthcare's standard coverage