Medication therapy management

What is the Medication Therapy Management (MTM) program?

If you’re in a Medicare drug plan and you have complex health needs, you may be able to participate in a MTM program.  MTM is a service offered by WellSense Health Plan at no additional cost to you!  The MTM program is required by the Centers for Medicare and Medicaid Services (CMS) and is not considered a benefit.  This program helps you and your doctor make sure that your medications are working. It also helps us identify and reduce possible medication problems. To help members get the best results from their medications, WellSense Health Plan contracts with Express Scripts to receive Medication Therapy Management Services, to eligible WellSense Health Plan members. Express Scripts partners with MTM vendors to complete member outreach, which may include Outcomes®, MedWatchers, and/or Arine. 

Who is eligible?

To take part in this program, you must meet certain criteria set forth in part by CMS. These criteria are used to identify people who have multiple chronic diseases and are at risk for medication-related problems. If you meet these criteria, we will send you a letter inviting you to participate in the program and information about the program, including how to access the program.  Your enrollment in MTM is voluntary and does not affect Medicare coverage for drugs covered under Medicare.

To qualify for WellSense Health Plan’s MTM program, you must meet one of the two following criteria:

1. Be an At-Risk Beneficiary as defined in 42 CFR §423.100 or
2. Meet ALL of the following criteria:
   1. Have at least 3 of the following conditions or diseases: 
      •    Alzheimer’s Disease
      •    Bone Disease-arthritis (osteoporosis, osteoarthritis, rheumatoid arthritis)
      •    Chronic Congestive Heart Failure (CHF)
      •    Diabetes
      •    Dyslipidemia
      •    End stage renal disease (ESRD)
      •    Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS)
      •    Hypertension
      •    Mental Health (including depression, schizophrenia, bipolar disorder, and other chronic/disabling mental health conditions)
      •    Respiratory Disease (including asthma, chronic obstructive pulmonary disease (COPD), and other chronic lung disorders), AND
   2. Take at least 8 covered Part D medications, AND
   3. Are likely to have medication costs of covered Part D medications greater than $1,623 per year.

To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of your medications: 

• Targeted medication review: at least quarterly, we will review all your prescription medications and contact you, your caregiver, your pharmacist, and/or your doctor if we detect a potential problem. This is a good time to ask any questions you have about the medication. If you have trouble remembering to take your medication, the pharmacist may be able to suggest ways to help you stay on track. If there are concerns about the dose or safety of a medication, the pharmacist will ask your permission to talk with your doctor to find the best solution for you. The estimated time commitment is about 15-30 minutes.
• Comprehensive medication review: at least once per year, we offer a free discussion and review of all of your medications by a pharmacist or other health professional to help you use your medications safely.  The pharmacist will meet with you face-to-face or via phone to review your prescriptions, vitamins, herbals, supplements and other over-the-counter medications. The pharmacist looks for potential medication conflicts, duplications, side effects or ways to save you money. You can ask any questions you have about your medications. After the review, the pharmacist will work with you, and your doctor if necessary, to resolve any medication-related concerns. The estimated time commitment is about 15-30 minutes. Following the review, you will get a written summary of this call, which you can take with you when you talk with your doctors.  This summary includes:
  • Recommended To-Do List (TDL): The list has steps you should take to help you get the best results from your medications. 
  • Personal Medication List (PML): The medication list will help you keep track of your medications and how to use them the right way. To obtain a blank copy of the Personal Medication List (PML) that can help you and your health care providers keep track of the medications you are taking, click here WellSense Health Plan PML.

For more information

If you take many medications for more than one chronic health condition contact your drug plan to see if you’re eligible for MTM, or for more information, please contact customer service at 855-833-8125.