A Medication Therapy Management Program (MTMP) is a Centers for Medicare & Medicaid Services (CMS) mandated program required of all Medicare Part D sponsors. The purpose of a MTMP is to help Medicare Part D members:

  • Understand their medications
  • Optimize therapeutic outcomes through improved medication use
  • Reduce the risk of adverse events, including drug-drug and drug-condition interactions

Blue Shield of California contracts with OutcomesMTMTM to provide MTMP services to eligible Medicare Part D members, including:

  • A local community pharmacist network to provide interactive medication reviews and clinical interventions
  • A Web-based application to document and report on pharmacist interventions and outcomes
  • Clinical algorithms to identify medication-related issues from Part D claims and notify local pharmacists for consultations with members and their physicians

Program services

Local community and consultant pharmacists who are part of the OutcomesMTMTM network receive notification of members who are eligible for the program. Additionally, pharmacists receive alerts for eligible members who may have medication-related issues or gaps in therapy. Pharmacists then work with members to resolve medication issues and provide recommendations to physicians to help optimize the medication regimen. Pharmacists will also provide MTMP services for members residing in long-term care facilities.

Member interventions

  1. Annual Comprehensive Medication Review (CMR)

    Pharmacists in the OutcomesMTM™ network will provide CMRs to eligible members. Pharmacists will meet one-on-one with members to review their complete medication history, including prescription, over-the-counter (OTC) and alternative medication therapies. The pharmacist will help resolve medication issues, identify ways to reduce out-of-pocket costs for prescriptions, and can contact the prescriber with recommendations.

    A written summary of the consultation, with relevant assessments and recommendations, will be provided to the member. The member’s prescribing physician or primary care physician may be contacted by the pharmacist to coordinate care or recommend therapy changes when necessary.

       Personal Medication List (PDF, 113KB)

  2. Targeted Medication Review (TMR)

    Pharmacists in the OutcomesMTM™ network will conduct TMR for eligible members, at least quarterly, throughout the year to identify potential gaps in medication therapy. Issues such as medication non-adherence, drug safety, and evidence-based treatments are addressed.

Prescriber interventions

  1. Pharmacist outreach

    Upon identification of medication-related issues from CMR or TMR, the pharmacist can contact the member’s physician to discuss identified issues and provide recommendations for consideration. Changes to medication therapies are approved by the prescriber and discussed with the member.

 

Program eligibility

Medicare Part D MTMP eligibility is based on CMS specifications. For 2020, Medicare Part D members are automatically enrolled in the program if they meet the following criteria:

1. CMS minimum thresholds (beneficiary must meet each criterion)

  • Have been diagnosed with two of the following chronic medical conditions:
    • Chronic heart failure (CHF)
    • Diabetes
    • Dyslipidemia 
    • Hypertension
    • Osteoporosis
    • Respiratory disease
  • Receive at least seven covered Part D drugs per month
  • Likely to incur at least $4,255 in annual Part D drug costs

If you are eligible, you will receive a letter introducing you to the program with information on how to schedule an appointment with a pharmacist. You may also receive automated or direct calls from pharmacists to provide more information about MTMP. If you don’t want to or cannot participate, you may contact Blue Shield of California to opt out of the program.

There is no additional cost to you. This program is not a plan benefit and you may decide not to participate, but it is recommended that you take full advantage of this free service if you meet the eligibility requirements.

For more information about our Medication Therapy Management Program, you may call the Blue Shield Medicare Member Services at at (800) 776-4466 [TTY: 711] 8 a.m. to 8 p.m., seven days a week, from October 1 through March 31, and 8 a.m. to 8 p.m., weekdays (8 a.m. to 5 p.m. Saturday and Sunday) from April 1 through September 30..