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 an 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-to-drug and drug-to-condition interactions

Blue Shield of California contracts with OutcomesMTM™ 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 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

Medication Therapy Management Program services

Local community and consultant pharmacists who are part of the OutcomesMTM™ 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 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 provide CMRs to eligible members. Pharmacists 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 and identify ways to reduce out-of-pocket costs for prescriptions. They can also contact the prescriber with recommendations.

The member will receive a written summary of the consultation, with relevant assessments and recommendations. The pharmacist may contact the member’s prescribing physician or primary care physician to coordinate care or recommend therapy changes when necessary.

Personal Medication List, English (PDF, 207 KB)

2. Targeted Medication Review (TMR)

Pharmacists in the OutcomesMTM™ network 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 a 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.

Medicare Part D Medication Therapy Management Program eligibility

Eligibility is based on CMS specifications. For 2021, 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 maintenance medications per month
  • Likely to incur at least $4,376 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, 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. However we recommended that you take full advantage of this service if you meet the eligibility requirements.

For more information about our Medication Therapy Management Program, call Blue Shield Customer Care at:

Blue Shield Medicare Advantage Prescription Drug Plan members:

(800) 776-4466 [TTY: 711]

Hours:

  • October 1 through March 31: 8 a.m. to 8 p.m., seven days a week
  • April 1 through September 30: 8 a.m. to 8 p.m., weekdays, and 8 a.m. to 5 p.m., Saturday and Sunday

Blue Shield Medicare Prescription Drug Plan members:

(888) 239-6469 [TTY: 711]

Hours:

  • October 1 through March 31: 8 a.m. and 8 p.m., seven days a week
  • April 1 through September 30: 8 a.m. to 8 p.m., weekdays, and 8 a.m. to 5 p.m., Saturday and Sunday