A Medication Therapy Management (MTM) program is not a benefit, but is a service we offer at no cost. You may be invited to participate in a program designed for your specific health and pharmacy needs. You can decide to not participate, but it's recommended that you take full advantage of this covered service if you're selected.
This program is offered through our partnership with Express Scripts, Inc. (ESI) and SinfoniaRx. Our MTM vendor, SinfoniaRx, will contact you when you're eligible. Once enrolled, you'll have the opportunity to speak with a health care professional that will help you to better manage your condition(s).
Members must meet all of the three following criteria for enrollment in the MTM program:
- Have at least three of the following chronic conditions
- Chronic Obstructive Pulmonary Disease (COPD)
- Chronic heart failure
- Hypertension (high blood pressure)
- Dyslipidemia (high cholesterol)
- End-Stage Renal Disease (ESRD)
- Bone Disease-Arthritis-Osteoporosis
- Must be taking at least Eight Part D covered medications
- Must spend more than $4,255 a year on Part D covered medications
Comprehensive Medication Review
MTM-eligible members are automatically enrolled in the program, sent an introductory letter, and will receive a phone call welcoming them to the program, providing the opportunity to opt-out or request a Comprehensive Medication Review (CMR).
Members may opt-out or request a CMR by returning an enclosed appointment form or calling the provided toll-free number. Members that request a CMR have a telephone appointment scheduled for a one-on-one consultation with a pharmacist or licensed pharmacy intern under the direct supervision of a pharmacist.
During the CMR, the member's entire medication profile is reviewed (including prescriptions, over the counter drugs (OTCs), herbal supplements, and samples) for appropriateness of therapy. Disease-specific goals of therapy and medication-related problems are discussed with the member, as well as any member-specific questions.
After the CMR, the member is mailed the standardized post-CMR takeaway letter which includes a Personal Medication List (PML) and Medication Action Plan (MAP) detailing the conversation with the pharmacist or licensed pharmacy intern. Meanwhile, all members that have not opted-out of the program receive ongoing Targeted Medication Reviews (TMRs) on at least a quarterly basis with each update of prescription claims.
Be sure to print a blank copy of the Personal Medication List (PML) for your own use.
TMRs identify opportunities for interventions based on systematic drug utilization review including:
- Cost savings
- Adherence to national consensus treatment guidelines
- Adherence to prescribed medication regimens
- Safety concerns
TMRs that result in the generation of alerts are categorized and prioritized based on the severity of the alert. The member or doctor would then be contacted in-person, or via phone call, text, mail, e-mail, electronic data exchange, or fax as appropriate for review of potential drug therapy changes.
TMR alerts that result in an outbound phone call to the member allow an additional opportunity to offer the member a CMR. Members that accept the CMR on the outbound TMR call receive the CMR as outlined above. Interventions resulting from person-to-person TMRs, non-person-to-person TMRs, and CMRs may result in provider contact in-person, or via fax, phone, text, e-mail, electronic data exchange, or mail, when appropriate.
How long does the program last?
The program runs from the time that the member meets eligibility requirements until the end of that calendar year. Eligible participants may be re-enrolled in the program the following January.
If you qualify for the MTM program, you'll receive:
An introductory letter
- This letter will tell you how to get started.
Comprehensive Medicine Review
- You'll have the chance to review your medicines with a pharmacist or other health care provider each year. This review will help you get the best results from your medicines.
- You'll get a letter that outlines this review and suggests action steps.
Targeted Medicine Review
- You or your doctor will be told if you should consider any changes in your medicines.
- You or your doctor may receive information that outlines this review.
See Requirements for Medication Therapy Management Programs from CMS.gov.
For more information on the Medication Therapy Management program, please call Member Service at 1-800-200-4255
(TTY: 711), 8:00 a.m. to 8:00 p.m. ET as follows: from April 1 through September 30, Monday through Friday, and from October 1 through March31, seven days a week.