Our Primary Care Physician Incentive Plan and Hospital Quality Improvement Plan allow both providers and hospitals to participate in an incentive program that rewards them for meeting certain nationally recognized quality standards and patient safety goals. Physicians must choose to participate in this program, and you can check to see if your physician group participates by using our Find A Doctor feature.
In 2004, we pledged $3 million to the Institute for Healthcare Improvement (IHI), an internationally recognized not-for-profit organization based in Massachusetts. The IHI will use funding to support its national patient safety campaign and will also apply $2.5 million of the total grant toward supporting Massachusetts hospitals conducting quality and patient safety improvement projects.
Recommended Monthly Dosing Level - This process checks to see that your monthly dosage of medication is consistent with both the manufacturer's and the FDA's monthly dosing recommendations and clinical information. Your doctor can also apply for an exception to QCD guidelines when medically necessary.
Additional prescription safety and quality measures include:
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 may decide not to participate, but it is recommended that you take full advantage of this covered service if you are selected.
This program is offered through our partnership with Express Scripts Inc. (ESI). ESI will contact you when you are eligible. When you are enrolled, you will have the opportunity to speak with a healthcare professional that will help you to better manage your conditions.
Members must meet all of the three following criteria for enrollment in the MTM program:
1. Have at least three of the following chronic conditions
Asthma/Chronic Obstructive Pulmonary Disease (COPD)
Chronic heart failure
Dyslipidemia (high cholesterol)
End-Stage Renal Disease (ESRD)
2. Must be taking at least 7 Part D covered medications
3. Must spend more than $3,144 a year on Part D covered medications
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 in the following January.
If you qualify for the MTM program, you will get:
This letter will tell you how to get started.
Comprehensive medicine review
You will 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 will get a letter that outlines this review and suggests action steps.
Targeted medicine review
You or your doctor will be told if you should think about any changes in your medicines.
You or your doctor may receive information that outlines this review.
Download an example of a full medicine review letter from CMS.gov.
For more information on the Medication Therapy Management program, please call Member Service at 1-800-200-4255 (TTY: 1-800-522-1254), 8:00 a.m. to 8:00 p.m. ET as follows: from February 15 through September 30, 8:00 a.m. to 8:00 p.m. ET, Monday through Friday, and from October 1 through February 14, 8:00 a.m. to 8:00 p.m. ET, seven days a week.
Disease management programs are free, voluntary services we offer to members who have one or more chronic health conditions. These programs are designed to help members with the day-to-day management of conditions such as coronary artery disease, diabetes, and other chronic conditions. If you are invited to take part in a disease management program, you have the right to decide whether or not to participate, but we recommend you take full advantage of the assistance the program can provide.