Medication Therapy Management Program

If your patient is a Medicare Prescription Drug Plan member and has complex health needs, your patient may be able to participate in a Medication Therapy Management (MTM) program. MTM is a service offered by our Health Plan at no additional cost to the member. This program ensures the medications being prescribed are clinically appropriate and helps us identify possible contraindications. The MTM program is required by the Centers for Medicare and Medicaid Services (CMS) and is not considered a benefit.

Eligibility

To take part in this program, the member must meet certain criteria set forth in part by CMS. These criteria are used to identify people who have multiple chronic diseases and are at risk for medication-related problems. If the member meets these criteria, the member will be sent a letter inviting them to participate in the program. The letter will also include information about the program and how to access the program. Enrollment in MTM is voluntary and does not affect Medicare coverage for drugs covered under Medicare.

To qualify for the MTM program, the member must:

  1. Be an At-Risk Beneficiary as defined by the provider OR 
  2. Meet ALL of the following criterion (a, b, and c): 
    1. Have 3 or more of the following conditions or diseases: 
      • Bone Disease - Arthritis - Osteoporosis
      • Chronic Heart Failure (CHF) 
      • Diabetes 
      • Dyslipidemia
      • Hypertension
      • Respiratory Disease - Asthma 
      • Respiratory Disease - Chronic Obstructive Pulmonary Disease (COPD) 
    2. Take at least 8 covered Part D medications 
    3. Are likely to have medication costs of covered Part D medications greater than $4,935 per year 

Clinical Review of Medications

To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of the member’s medications:

  • Targeted medication review: at least quarterly, the Plan will review member’s prescription medications and contact the member, their caregiver, and the provider if we detect a potential problem.

  • Comprehensive Medication Review (CMR): at least once per year, we offer a free discussion and review of the member’s medications by a pharmacist or other health professional to ensure the member is using the medications safely. This review, or CMR, is provided to the member confidentially via telephone by a licensed healthcare professional. The CMR may also be provided in person or via telehealth at the provider’s office, pharmacy, or long-term care facility. If the member or the member’s caregiver are not able to participate in the CMR, this review may be completed directly with the provider. These services are provided on behalf of the Plan. This review takes about 30 minutes. Following the review, the member will get a written summary of the call, which the member can take with them to their next doctor’s appointment. This summary includes:

    • Medication Action Plan (MAP): The action plan has steps the member should take to help you get the best results from your medications. 

    • Personal Medication List (PML): The medication list will help the member keep track of your medications and how to use them the right way.

Contact Us

For more information on the MTM program, please call our Medicare Customer Care Advocates at  1-877-883-9577 (TTY 711), available Monday – Friday from 8 a.m - 8 p.m. ET. From Oct. 1 to Mar. 31, representatives will be available seven days a week from 8 a.m. - 8 p.m. ET.

 

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