Medication Therapy Management
The Highmark Medication Therapy Management (MTM) program is an integrated pharmacy experience that helps Medicare Advantage members with chronic conditions and high prescription costs better manage their medications.
We'll help you make a plan
We want to identify potential gaps in care as early as possible. That’s why we work with you to create a Medication Action Plan. This plan is a simple, easy-to-understand guide for you to discuss with your doctor about potential drug therapy problems associated with your particular condition, helpful recommendations, and important counseling information.
Making sure that you can afford the medications you need is an important part of the MTM program, too. We keep your personal budget in mind and give recommendations on cost savings opportunities wherever we find them.
Extra Highmark help managing your prescriptions
The MTM program provides an extra layer of support by assigning a pharmacist to work directly with you to help ensure that your prescriptions are safe and working to their best ability. Your pharmacist will provide:
— A Comprehensive Medication Review (CMR) - Every year, you or your caregiver will meet with a pharmacist or nurse to go over your medications. This is a one-on-one consultation to review your entire medication profile, including prescriptions, over-the-counter (OTC) medications, herbal supplements and samples. During this review we will check the appropriateness of your therapy and screen for potential interactions. You’ll also discuss therapy goals, medication related problems and any specific questions you have will be addressed. At the end, you’ll receive a Personal Medication List and Medication Action Plan detailing your conversation as well as information on how to safely dispose of medications you no longer take.
— Targeted Medication Reviews (TMR) - At least quarterly, your provider will be contacted to keep you on the right track between CMRs. TMRs focus on identifying cost savings, safety concerns, prescribing adherence to national treatment guidelines, and whether you’ve been following your medication regimen.
— Coordination services - We’ll work directly with your doctor and /or pharmacy, when needed, to help make sure everything goes smoothly.
The MTM program is free for qualified Medicare members. If eligible, you’ll be automatically enrolled and receive instructions in the mail about how to take advantage of the program’s great services.
Eligibility for the MTM program
This program is for Medicare members who suffer from at least three of the following conditions (based on prescription claims data):
— Alzheimer's disease
— Bone disease / arthritis (including osteoporosis, osteoarthritis, and 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 chronic / disabling mental health conditions)
— Respiratory disease (including asthma, chronic obstructive pulmonary disease (COPD), and chronic lung disorders)
In addition to having at least three of these conditions:
For 2024 you must also be prescribed at least seven chronic or maintenance Part D medications and are likely to incur annual costs of at least $5,330 in 2024 for all covered Part D drugs.
For 2025 you must also be prescribed at least eight chronic or maintenance Part D medications and are likely to incur annual costs of at least $1,623 in 2025 for all covered Part D drugs.
If you do not meet these requirements, you may still be enrolled in the MTM program if Highmark determines you to be an at-risk beneficiary who could benefit from this service.
Enrolling in the MTM program
You do not need to apply for this program. If you meet the above eligibility requirements, then you’ll be enrolled in the MTM program automatically. If you do not want to participate in the program, then you can choose to opt out at any time.
Service documents
Take a look at the PDFs below if you’d like to see samples of the types of documents you will receive as a participant. These samples are intentionally left blank.
Contact information
There are several ways to contact us if you have questions about MTM program eligibility or services:
— Call the 1-800 number listed in your welcome letter.
— Call the Member Service number listed on the back of your Highmark member card.