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:
- Local community pharmacists and consultant pharmacists (Pharmacy Care Centers) 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 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.
1. Annual Comprehensive Medication Review (CMR)
The community and consultant pharmacists 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 pharmacists 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.
Standard Patient Takeaway, English (PDF, 787 KB)
Standard Patient Takeaway, Spanish (PDF, 831 KB)
2. Targeted Medication Review (TMR)
The pharmacists conduct TMR for eligible members on at least a quarterly basis throughout the year to identify potential gaps in medication therapy. The TMR addresses issues such as medication non-adherence, drug safety, and evidence-based treatments.
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. Prescribers approve changes to medication therapies and discuss these changes with the member.
Medicare Part D Medication Therapy Management Program eligibility
Eligibility is based on CMS specifications. For 2023, 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 three of the following chronic medical conditions:
- Chronic heart failure (CHF)
- Respiratory disease – Chronic Obstructive Pulmonary Disease (COPD)
- Receive at least eight covered Part D maintenance medications per month
- Likely to incur at least $4,935 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 recommend 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 the number on your ID card.