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AAU Provider Update: Medication Costs on ADvantage Service Plans

May 20, 2011

The incorrect assignment of medications to the W1111 Waiver Medication code can unnecessarily add to the cost of an ADvantage Member’s Service Plan and potentially put the Member over the ADvantage cost cap.. This bulletin is designed to assist the Case Manager in appropriately assigning medications to the proper pay source.

Codes used for Medications:

M1111: Medications paid through Medicare benefit

S1111: Medications paid through the SoonerCare/Medicaid benefit

W1111: Medications paid through ADvantage Waiver benefit

N1111: Medications, including over the counter, paid through other sources

Factors to consider when assigning medications a pay source on an ADvantage Service Plan:

  • If an ADvantage Member receives Medicare benefits, including Medicare Hospice, Medicare will be the pay source (M1111) for the medications in almost all instances, and the W1111 service code should not be used on the Service Plan.
  • If an ADvantage Member receives ADvantage Hospice services, the Case Manager should carefully check to see which medications are paid through ADvantage Hospice benefit.  If the medications are paid through ADvantage Hospice, they should not be added to the plan as they are included in the ADvantage Hospice daily authorization.
  • If an ADvantage Member receives Veterans Administration (VA) benefits, the case manager should carefully review whether the VA is covering any of the Member’s medications.  If so, the medications should be listed using the N1111 code.
  • When an ADvantage Member’s medications are paid through the SoonerCare and ADvantage benefit, the first six medications should be listed on the Member’s plan as S1111.  The remaining medications should be counted and listed as W1111.  The maximum number of 7 medications should not be used on the Service Plan unless the Member actually receives 7 medications in addition to the 6 SoonerCare/Medicaid-covered medications.

If you have any questions or concerns regarding the information provided above, please feel free to contact us via email at Provider Questions.

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