Medication Therapy Management Program services

A Medication Therapy Management (MTM) Program is required by the Centers for Medicare & Medicaid Services (CMS) of all Medicare Part D sponsors. The purpose of a MTM program is for a pharmacist or other health professional to help Medicare Part D members with complex health needs manage their medications.

Pharmacists from Blue Shield of California or our contracted vendor, Outcomes^TM, will provide MTM services for eligible members. These pharmacists are from Outcomes^TM, the local community, or a part of our pharmacist provider network and will provide medication reviews by phone or in-person to help members:

• Understand their medications and conditions
• Reduce the risk of side effects from medication use, including drug to drug interactions
• Assess if there are lower cost alternatives

Medicare Part D Medication Therapy Management Program Eligibility

Members will be enrolled in our MTM program if they meet the following CMS minimum thresholds (beneficiary must meet each criterion):

1. Have been diagnosed with three of the following chronic medical conditions:
   • Alzheimer's Disease
   • Bone diseases – arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis) 
   • Chronic 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)
2. Receive at least eight or more covered Part D maintenance medications per month
3. Likely to incur at least $1,663 in annual Part D drug costs

If you are eligible, you will receive a letter introducing you to the program and including information on how to schedule an appointment with a pharmacist. You may also receive automated or direct calls from a health professional who will provide more information about MTM.

There is no additional cost to you and you may decide not to participate. If you do not want to or cannot participate, contact Blue Shield of California to opt out of the program. 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 service at the number on your ID card.

Medication Therapy Management Program Services

The MTM program consists of two main services:

• Annual Comprehensive Medication Review (CMR)
• Targeted Medication Review (TMR)

Pharmacists will work directly with eligible members and providers to help make sure that members get the most benefit from the medications they take.

1. Annual Comprehensive Medication Review (CMR)

Pharmacists will have one-on-one consultations by phone or in-person with members to review their medication history, including prescription, over-the-counter (OTC), and alternative medication therapies.

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

Standard Patient Takeaway, English (PDF, 161 KB)

Standard Patient Takeaway, Spanish (PDF, 641 KB)

Standard Patient Takeaway, Arabic (PDF, 467 KB)

Standard Patient Takeaway, Armenian (PDF, 700 KB)

Standard Patient Takeaway, Simplified Chinese (PDF, 383 KB)

Standard Patient Takeaway, Traditional Chinese (PDF, 518 KB)

Standard Patient Takeaway, Farsi (PDF, 494 KB)

Standard Patient Takeaway, Khmer (PDF, 413 KB)

Standard Patient Takeaway, Korean (PDF, 404 KB)

Standard Patient Takeaway, Russian (PDF, 459 KB)

Standard Patient Takeaway, Tagalog (PDF, 508 KB)

Standard Patient Takeaway, Vietnamese (PDF, 604 KB)

2. Targeted Medication Review (TMR)

A TMR addresses a specific identified medication issue or assesses if there is a potential medication-related problem and will be conducted for eligible members at least quarterly throughout the year.

Pharmacists will follow up with members as needed and may contact the member’s prescribing physician or primary care physician to recommend therapy changes.