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Medication Therapy Management Program

Members enrolled in Blue Medicare HMO^sm or Blue Medicare PPO^sm with Medicare prescription drug benefits or Blue Medicare RX^sm may be eligible for the medication therapy management program (MTMP), in accordance with CMS requirements. The purpose of the program is to provide medication therapy management services to targeted members. These services are designed to ensure that covered Part D drugs are appropriately used to optimize therapeutic outcomes by improving medication use and reducing the risk of adverse drug events including adverse drug interactions. The MTMP is developed in cooperation with licensed and practicing pharmacists and physicians.

Who's eligible for the MTMP?
Individual members eligible for the MTMP services must meet all three (3) criteria below:

• Have at least three (3) of the following chronic conditions: diabetes, chronic obstructive pulmonary disease (COPD), asthma, hypertension, dyslipidemia, chronic heart failure (CHF), osteoporosis, osteoarthritis, or depression.
• Have claims for a minimum of six (6) different chronic/maintenance Part D covered medications.
• Are likely to incur a minimum threshold of $ 3,144.00 in annual drug costs for covered Part D medications.

How do eligible members enroll?
Eligible members are automatically enrolled in the program. A letter and participation form will be mailed to eligible members informing them of their enrollment in the program. Members are encouraged to return the participation form in the envelope provided or call a toll-free phone number (1-866-686-2223 or TTY users call 711 or 1-800-855-2881) to speak with a pharmacist regarding their medications. Participation in the program is voluntary.

What services does the MTMP provide?
The MTM services include the following interventions for members and prescribers.

• An annual comprehensive medication review (CMR) which includes an interactive, a person-to-person consultation via the telephone between the member and pharmacist or nurse.
• Quarterly targeted medication reviews (completed electronically based on prescribed medications). Members' prescribers are sent an intervention letter to identify specific medication related problems, a necessary change in therapy, or other opportunities to optimize medication use. The prescriber is to assess the potential risk and to contact the member or dispensing pharmacy directly if a change in therapy is warranted. The MTMP will follow up with members and/or prescribers when necessary.
• Drug utilization reviews completed real-time online by the dispensing pharmacy. A real-time online pharmacy adjudication system scans all incoming prescription claims against the medication history of beneficiaries enrolled in the MTMP to look for potential medication related problems. The dispensing pharmacist receives a message identifying an intervention opportunity and performs the intervention through discussion with either the member and or with the prescriber as appropriate.

What is a Comprehensive Medication Review (CMR)?
A Comprehensive Medication Review (CMR) is interactive review of your medications completed over the telephone with a pharmacist or nurse. He/she will:

• Review the medicines you take
• Create a personal medicine list
• Help you understand how your medicines work
• Tell you about side effects from your medicines
• Answer any questions or concerns you have

Upon completion of the CMR the member will be mailed an individualized written summary of the CMR including a personal medication list and medication action plan in the standardized formats required by CMS.

How do members opt out (decline) participation in the program?
Members may opt out from participating in the program by calling the telephone number listed in the notification letter (1-866-686-2223 or TTY users call 711 or 1-800-855-2881) between 10:00 a.m. and 6:00 p.m. Eastern time, Monday through Friday (except major holidays). Members may also refuse or decline individual services without having to opt out from the program.

What are the program goals?

• Educate members regarding their medications
• Increase adherence to medication therapy
• Identify and prevent medical complications related to medication therapy

Additional information regarding the MTMP and access to a blank Personal Medication List from the CMR standardized format is available at the following link.

Members should also refer to their Evidence of Coverage for more details on the MTMP.

Benefits, formulary, pharmacy network, premium and/or co-payments/co-insurance may change on January 1 of each year. Please contact BCBSNC for details.

Blue Cross Blue Shield of North Carolina (BCBSNC) is a Medicare Advantage organization with a Medicare contract to provide HMO and PPO plans. BCBSNC is a Medicare-approved Part D sponsor. BCBSNC does not discriminate based on race, ethnicity, national origin, religion, gender, age, mental or physical disability, health status, claims experience, medical history, genetic information, evidence of insurability or geographic location within the service area. All BCBSNC items and services are available to all eligible beneficiaries in the service area.

Limitations, copayments, and restrictions may apply. You must be entitled to Medicare Part A and enrolled in Medicare Part B and must reside in the CMS-approved service area. You must continue to pay your Medicare Part B premium.

If you would like Medicare Advantage or Part D documents in a different language or format, or your coverage has ended and you need proof of coverage or a Certification of Health Insurance Coverage, you can call us 7 days a week, 8a.m. to 8 p.m.

The information on this page is current as of 10/01/2012.

Y0079_5875 CMS Approved 10012012