Medication Therapy Management (MTM) Program Regence offers a Medication Therapy Management (MTM) program to ensure you are receiving the most effective medications, while also helping to reduce the risk of side effects and interactions as well as your out-of-pocket costs. The program is paid in full by your plan. This means that you can receive the benefits of the MTM program at no cost to you. There is no change to insurance benefits, co-pays, prescription coverage, or available doctors or pharmacies. The MTM program is designed to help members who meet the below criteria to get the most from their medications: Two or more chronic diseases including: o Osteoporosis o Rheumatoid Arthritis o Diabetes o Dyslipidemia o Depression o Asthma o Chronic Obstructive Pulmonary Disease (COPD) o Chronic Heart Failure (CHF) o Hypertension o HIV/AIDS Eight or more maintenance medications for chronic conditions Likely to incur a yearly drug spend of $3,507 Regence members who meet the criteria will be sent an introduction letter which describes the MTM program. Specially trained pharmacists work closely with you and your doctors to solve any problems related to medicines and to help you get the best results. You will be contacted by a pharmacist for an interactive person-to-person consultation to review all of your medications and answer any questions that you may have. Following the consultation, the pharmacist will provide you with a medication review package which contains several helpful documents all related to your medication therapy and consultation. A Personal Medication List template and a Medication Action Plan template are included with this document. Medicare requires that MTM programs automatically enroll those who qualify through the calendar year, but participation is voluntary, and members are given the opportunity to opt out at any time. If you have any questions or choose to opt out from the MTM program, please call the Pharmacy Department at 1-855-356-3212 Monday Friday 6 am to 6 pm.
DOB: This medication list was made for you after we talked. We also used information from patient claim data both prescription and medical, patient self-reported data including medications and directions for use, and prescriber feedback 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 in your care team 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. Allergies or side effects: DATE PREPARED: Page 1 of 4
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, DOB: (Continued) Other Information: If you have any questions about your medication list, call Pharmacy Services MTM Clinical Call Center, 1-855-356-3212, Monday through Friday 7am to 7pm MST. 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 0938-1154. The time required to complete this information collection is estimated to average 40 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 21244-1850. Page 4 of 4
MEDICATION ACTION PLAN FOR 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 in your care team. Share this with your family or caregivers too. What we talked about: DATE PREPARED: What I need to do: What I did and when I did it: My follow-up plan (add notes about next steps): Questions I want to ask (include topics about medications or therapy): Page 1 of 2
If you have any questions about your action plan, call Pharmacy Services MTM Clinical Call Center, 1-855-356-3212, Monday through Friday 7am to 7pm MST. Page 2 of 2