Medication Therapy Management (MTM) Programs are required by the Centers for Medicaid and Medicare Services (CMS) for all Part D Prescription Drug Plans (PDP) and Medicare Advantage Plans (MA). This valuable program is offered free of charge and is not considered a benefit. There are no additional co-pays or charges to you.
How do I benefit from MTM?
- Each medication your doctor prescribes is reviewed by an MTM trained Pharmacist when you have your prescription filled.
- This review helps you get the greatest benefit from your medication.
- This helps you reduce the risk of harmful side effects.
- Your pharmacist can suggest to you and your doctor alternatives that can lower your costs.
- You will receive a Comprehensive Medication Review (CMR) at least annually. The CMR usually takes about 30 minutes to complete.
How will I be contacted and offered MTM services?
MTM Eligible enrollees will be contacted by the health plan via mail and/or phone to offer MTM services. MTM eligible members are contacted telephonically on a monthly basis to remind them of the importance of the Comprehensive Medication Review (CMR). These monthly reminders continue until the member completes a CMR or notifies the plan they do not want to be called again. Members may also be contacted directly by their local pharmacy. MTM Services may be conducted in person at the member’s local pharmacy or telephonically with the local pharmacy or the health plan. CMRs are conducted at least annually and usually take about 30 minutes to complete. Targeted Medication Reviews (TMR) are conducted quarterly in person at the member’s local pharmacy or telephonically with the local pharmacy or with the health plan. The TMR usually takes 5 or 10 minutes and covers important issues regarding medication use. Some examples are: adherence to medications, side effects, drug interactions, over and/or under-utilization, or medications that may be associated with higher risk in the elderly.
What is my Comprehensive Medication Review (CMR)?
- A Comprehensive Medication Review (CMR) is a consultation with a qualified pharmacist and goes over the following:
- Why each medication is prescribed and whether any medications are potentially unnecessary.
- If each medication is effective.
- If each medication could be causing side effects, worsening other health conditions, or interacting with other medications.
- If a medication regimen can be made more affordable or simplified (such as fewer pills or a more convenient dosing schedule).
- If medications are being taken appropriately to get the most benefit from them.
After your CMR has been completed, you will be provided with two documents via the mail:
- A Medication Action Plan (MAP):
Includes steps you should take to get the best results from your medications.
- A Personalized Medication Record (PMR):
Helps you keep track of your medications and how to use them properly.
- You can Download a blank Personalized Medication Record to track your additional prescriptions.
How do I get started?
MTM Programs are required by CMS to include enrollees that meet the following requirements:
- Incur one-fourth of specified annual cost threshold ($4,935) in previous three months
- Multiple chronic diseases
- Multiple medications
Optimum HealthCare, Inc. has developed specific criteria using the general guidelines provided by CMS to enhance the care and quality of life of our Medicare MTM members. Medicare enrollees will be automatically enrolled in the program if they meet all of the criteria below. However, participation is voluntary and members are given the opportunity to dis-enroll (opt-out) at any time. This program is not considered a benefit.
- Medicare enrollee must have any three (3) of the chronic medical conditions listed below:
a) Chronic Heart Failure (CHF)
e) Respiratory Disease-Asthma
f) Respiratory Disease-Chronic Lung Disorders
g) Respiratory Disease-Chronic Obstructive Pulmonary Disease (COPD)
- The Medicare enrollee must receive a minimum of eight (8) chronic/maintenance Part D medications per month.
- The Medicare enrollee must incur one-fourth of the specified annual cost threshold ($4,935) in previous three months
- Medicare enrollees eligible for the MTM program will be enrolled automatically. Participation is voluntary and members are given the opportunity to dis-enroll (opt-out) at any time
- At any time, a beneficiary, a beneficiary’s representative or beneficiary’s physician may request that they not participate in this program and they will no longer be enrolled/eligible. Members will also be dis-enrolled if they leave the Plan. Please Note: Disenrollment from the MTM program does not dis-enroll you from your health plan.
4. At-risk beneficiaries (ARBs) under a Drug Management Program (DMP), regardless of whether those individuals meet other MTM targeting criteria.
- All existing ARBs – that is, beneficiaries with an active coverage limitation under a DMP as of January 1, 2023, although such limitation may have commenced prior to January 1, 2023 – as well as ARBs identified on or after January 1, 2023, must be targeted for enrollment in MTM.
- There may be some overlap between the populations that meet the eligibility criteria under (1) and (2), e.g., a beneficiary who is an ARB under the plan’s DMP (2) who also meets MTM criteria based on having multiple chronic diseases, multiple Part D drugs and meeting the cost threshold (1). Despite the possibility for overlap, sponsors must identify all targeted beneficiaries eligible for MTM and apply the same requirements for targeting regardless of whether the beneficiary meets the criteria under (1), (2), or both.
How do I know if I qualify for MTM Services
After an MTM Eligible enrollee meets the above mentioned requirements they will be notified of their eligibility through a direct mailing and/or an automated call from the health plan.
For additional information, please contact Optimum HealthCare, Inc.’s Member Services at 1-866-245-5360 or, for TTY/TDD users 711. Our Hours are October 1 to March 31 from 8:00 am to 8:00 pm EST. 7 days a week and April 1 to September 30 from 8:00 am to 8:00 pm EST. Monday through Friday or visit www.youroptimumhealthcare.com.