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2017 Medication Therapy Management/Quality Assurance Program

The Medication Therapy Management Program is a requirement for all Medicare Part D sponsors. This program targets specific Medicare recipients and looks to ensure that the prescription medications that they are taking are being used appropriately and also works toward creating the most favorable therapeutic outcomes through improved medication use. The MTM program looks at the member’s medication usage for safe prescribing practices, with the goal to reduce a member’s risk of any adverse events, including adverse drug interactions.


Medication Therapy Management Program Eligibility Criteria

Beneficiaries are enrolled in the MTM program when they meet all of the following criteria:

  • Taking multiple covered chronic/maintenance Part D medications per month. The minimum number of medications that a beneficiary must be taking per month is six.
  • Total drug cost exceeds the monthly or quarterly threshold amount that is a determined off of the annual threshold amount set by CMS each year. The annual drug cost threshold for this year is $3,919.
  • Having a minimum of three chronic disease states from one of the following conditions: Alzheimer’s Disease, Chronic Heart Failure (CHF), Diabetes, Dyslipidemia, Depression, and COPD.

Beneficiaries that meet these three criteria are auto-enrolled into the program. Analysis is done on a quarterly basis to identify members that meet the above criteria, and to enroll them in the MTM program.

MTM Notifications and Mailings


Introduction Letter

(Members Targeted Quarterly)

• The introductory letter is sent to the member after they meet the eligibility criteria listed above. This letter notifies the member that they qualify for the MTM program at no charge.

• This is an optional program for members, in which members can opt out at their choice at any time. To "OPT-OUT" of the MTM program, the beneficiary may call 1-800-546-5677, 24 hours a day, 7 days a week (TTY 866-706-4757).

• The introductory letter also includes an offer of a Comprehensive Medication Review (CMR), including a list of the member’s prescriptions medications filled for the previous quarter, and any identified savings or therapy change observations.

Comprehensive Medication Review (CMR)

• A Comprehensive Medication Review is an interactive, person-to-person consultation between the member, or a member’s appointed representative, and one of our qualified pharmacists. This consultation consist of a thorough review of the member’s medication use, including prescription, Over-the-Counter (OTC), and herbal products.

• If interested in receiving a comprehensive medication review, call 1-800-546-5677, TDD/TYY 1-866-706, to schedule an appointment for a review at a later time. Members that receive a CMR consultation will also receive an individualized follow-up summary letter that covers

Targeted medications Reviews (TMR)

Quarterly analysis is conducted on enrolled beneficiary prescription claims. Notifications can be sent out to the member based on this analysis that could include:

• Medication and therapy adherence

• Generic substitution and cost savings opportunities

• Drug-Drug Interactions

• Therapy recommendations to discuss with their prescriber

Prescriber Interventions

Prescribers can be notified via fax or mail regarding an MTM enrollee that they have written prescriptions for any of the following items:

• Therapeutic Interchange opportunities

• Medication Safety Alerts/ Drug Recalls

• Over/Under Medication Utilization


This program is voluntary and free to members. A team of pharmacists and doctors developed the program for us. The program can help make sure that our members are using the drugs that work best to treat their medical conditions and help us identify possible medication errors.

This program is not a benefit; therefore if you qualify for our program based on our criteria, we will automatically enroll you in the program and send you information. If you decide not to participate, please notify us and we will withdraw your participation from the program.

If you have any questions, you may contact our Pharmacy Services Department at 1-800-523-3142. We are available to help you between the hours of 7:30 a.m. and 5:00 p.m., five days a week. TTY users may call 711.

H0545_RAY2013_191 CMS Approved 05/17/2013                   Updated 05/09/2013