Medication Therapy Management

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.

Who is eligible?

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

  • Diabetes

  • Hypertension

  • Dyslipidemia (high cholesterol)

  • Depression

  • End-Stage Renal Disease (ESRD)

  • Osteoporosis

2. Must be taking at least 7 Part D covered medications

3. Must spend more than $3,017 a year on Part D covered medications

MTM eligible members are automatically enrolled into the program and sent an Intro Letter that welcomes them into the program, provides the opportunity to opt-out, and offers the opportunity to request a Comprehensive Medication Review (CMR). The member 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. If the introductory letter is returned via USPS, an attempt will be made via phone call to contact the member in an effort to complete their CMR.

During the CMR, the member's entire medication profile is reviewed (including prescriptions, 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 and Medication Action Plan detailing the conversation with the pharmacist or licensed pharmacy intern. Meanwhile, all members that have not opted-out of the program receive on-going Targeted Medication Reviews (TMR) on at least a quarterly basis with each update of prescription claims.

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, and safety concerns. TMRs that result in the generation of alerts are categorized and triaged based on the severity of the alert. The member or physician would then be contacted via phone or mail as appropriate for review of potential 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 via phone call, fax, 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 in the following January.

If you qualify for the MTM program, you will get:

An Introductory letter

  • 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.

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: 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.