<Date> <First name> <Last name> <Address 1> <Address 2> <City> <State> <Zip> <Member ID number> Dear <member name>:
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1 <Date> <First name> <Last name> <Address 1> <Address 2> <City> <State> <Zip> <Member ID number> Dear <member name>: Thank you for talking with me on <date> about your health and medications. Medicare s MTM (Medication Therapy Management) program helps you understand your medications and use them safely. This letter includes an action plan (Medication Action Plan) and a medication list (Personal Medication List). The action plan has steps you should take to help you get the best results from your medications. The medication list will help you keep track of your medications and how to use them the right way. Have your action plan and medication list with you when you talk with your doctors, pharmacists, and other health care providers. Ask your doctors, pharmacists, and other healthcare providers to update them at every visit. Take your medication list with you if you go to the hospital or emergency room. Give a copy of the action plan and medication list to your family or caregivers. If you want to talk about this letter or any of the papers with it, please call MTM Program at between the hours of 8am and 5pm, Monday through Friday, Pacific time (TTY users call 711). We look forward to working with you and your doctors to help you stay healthy through the MTM program. Sincerely, XXXX, RPh Clinical Pharmacist 1
2 MEDICATION ACTION PLAN FOR <First name> <Last name> <DOB> This action plan will help you get the best results from your medications if you: 1. Read What we talked about. 2. Take the steps listed in the What I need to do boxes. 3. Fill in What I did and when I did it. 4. Fill in My follow-up plan and Questions I want to ask. Have this action plan with you when you talk with your doctors, pharmacists, and other healthcare providers. Share this with your family or caregivers too. DATE PREPARED: <Date> 2
3 MEDICATION ACTION PLAN FOR <First name> <Last name> <DOB> My follow-up plan (add notes about next steps): Questions I want to ask (include topics about medications or therapy): If you have any questions about your action plan, call Moda Health s MTM Program at between the hours of 8am and 5pm, Monday through Friday, Pacific time (TTY users call 711). 3
4 This medication list was made for you after we talked. We also used information from Medicare part D claims data. Use blank rows to add new medications. Then fill in the dates you started using them. Cross out medications when you no longer use them. Then write the date and why you stopped using them. Ask your doctors, pharmacists, and other healthcare providers to update this list at every visit. Keep this list up-to-date with: prescription medications over the counter drugs herbals vitamins minerals If you go to the hospital or emergency room, take this list with you. Share this with your family or caregivers too. DATE PREPARED: <Date> Allergies or side effects: 4
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7 Other Information: If you have any questions about your medication list, call Moda Health s MTM Medicare Program at between the hours of 8am and 5pm, Monday through Friday, Pacific time (TTY users call 711). According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB number for this information collection is The time required to complete this information collection is estimated to average minutes per response, including the time to review instructions, searching existing data resources, gather the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, Attn: PRA Reports Clearance Officer, 7500 Security Boulevard, Baltimore, Maryland
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