Medication Therapy Management

Optimize the use of your medications to obtain better therapeutic results:

The Medication Therapy Management Program (MTM) is designed to help eligible members with multiple conditions reconcile their medication profile and identify and resolve any drug-related problems to optimize therapeutic outcomes. The Program is individualized, voluntary, and complementary to the drug coverage.

The benefits of the Program include a complete evaluation of the drug therapy to ensure adequate and safe use of medications. This assessment consists of education and recommendations to the member, as well as for the physician or other health care professionals, at no additional cost to the member. This program is not considered a benefit of the drug coverage. However, it is offered at no additional cost to the member.

Eligibility Criteria for Elite Health Plan’s MTM Program

Members who meet the following three (3) criteria:

If you have incurred prescription drug costs under Part D totaling one-fourth of specified annual cost threshold ($1,276) in previous three months

2. If you have at least three (3) chronic conditions from the following list:

Diabetes (DM)
Dyslipidemia
Hypertension (HTN)
Chronic Heart Failure (CHF)
End-Stage Renal Disease (ESRD)
Alzheimer's Disease Bone Arthritis Disease (including osteoporosis, osteoarthritis, and rheumatoid arthritis)
Human Immunodeficiency Virus (HIV)/Acquired Immunodeficiency Syndrome (AIDS)
Mental Illness (depression, schizophrenia, bipolar disorder, and chronic/disabling mental health conditions)
Respiratory Disease (asthma, chronic obstructive pulmonary disease (COPD), and chronic lung disorders)

3. If you use at least eight (8) medications covered under Medicare Part D, including all maintenance medications.

OR Members considered at risk of opioid overutilization with an active coverage limitation of any of these drugs under the Drug Management Program (DMP)

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 1st of the current year, although such limitation may have commenced prior to the current year– as well as ARBs identified on or after the current year will be targeted for enrollment in MTM.
There may be some overlap between beneficiaries that meet the eligibility criteria under (1) and (2), e.g., a beneficiary who is an ARB under the Elite Health Plan 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, Elite Health Plan will 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.

If the member does not wish to participate in the program, he/she may choose accordingly.

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 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.

MTM Services and Materials

Members enrolled in the program will receive the following:

Welcome Letter (through mail), explaining the program in detail.
Telephone calls to schedule an appointment for a comprehensive medication review.
A telephone call to conduct an annual comprehensive medication review (CMR) to identify potential drug therapy problems and create an action plan to resolve them. A nurse or pharmacist will call either the member or his/her authorized representative. The interview takes 20 to 30 minutes, depending on the member.
During the comprehensive medication review with a qualified professional, the member will receive individualized education about their medication therapy and health conditions.
Written information about the safe disposal of expired medications or those no longer in use, including controlled substances such as opioids (a downloadable version of this information is available at the end of this page).
Follow-up evaluations by a health care professional, including quarterly targeted medication reviews (TMR), such as monitoring of medication utilization.
Consultations and interventions with prescribing physician and/or other health care professionals to optimize therapy and resolve any medication-related issues.
Referrals to other company programs will be offered, if necessary.
The member will receive, within 14 days after the interview, a summary of the interview that includes the updated patient medication list and the action plan determined according to the member’s drug therapy.

Fact Sheet: Safely Managing Your Pain Medications

Information: Safe Disposal of Medications

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. CMRs are conducted at least annually and usually take about 30 minutes to complete. Targeted Medication Reviews (TMR) are conducted quarterly. The TMR 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 or other healthcare professional 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 in the link provided below.

How do I get started?

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 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.