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Medication Therapy Management Program

Members enrolled in Blue Medicare HMOsm or Blue Medicare PPOsm with Medicare prescription drug benefits or Blue Medicare RXsm 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 is 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), osteoorosis, 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 $ 3,017.00 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 user call 711 or 1-800-855-2881) to speak with a pharmacist regarding their medications. Participation in the program is voluntary.

How do enrolled members decline participation in the program?
Enrolled members may opt out of the program by calling the toll free number 1-866-686-2223 or TTY users call 711 or 1-800-855-2881. Members may refuse or decline individual services without having to disenroll from the program.

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 happens once members are-enrolled in the program?
Members will be offered a Comprehensive Medication Review (CMR) with a pharmacist or nurse. Upon completion of the CMR, members will receive an individualized written summary of the CMR including a personal medication list and medication action plan in the standardized formats required by CMS.

Upon completion of the CMR, the prescriber may receive contact from the pharmacist via telephone, mail, or facsimile to resolve medication-related problems or optimize medication therapy.

What are the goals of the program?

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

View additional information regarding the MTMP. Access a blank Personal Medication List from the CMR standardized format.

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

Blue Cross and Blue Shield of North Carolina is an HMO, PPO, and PDP plan with a Medicare contract. Enrollment in Blue Cross and Blue Shield of North Carolina depends on contract renewal. Blue Cross and Blue Shield of North Carolina 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 Blue Cross and Blue Shield of North Carolina items and services are available to all eligible beneficiaries in the service area.