Medication Therapy Program & Transition Fills
See if you qualify for support managing your medications, or find help if a drug you currently take is not covered under your plan's current formulary.
New or current members may be affected by yearly changes in our formulary. If your current drug is not on our formulary, has restrictions, or will no longer be covered and you need help switching to a different drug, see our Medication Transitions information below.
Table of Contents:
Medication Therapy Management (MTM) Program
The Martin's Point Health Care Medication Therapy Management (MTM) Program is all about you and your health. The MTM Program helps you get the most out of your medications by:
- Preventing or reducing drug-related risks
- Supporting good lifestyle habits
- Providing information for safe medication disposal options
Who qualifies for the MTM Program?
Your participation in the MTM Program is voluntary and does not affect your coverage. This is not a plan benefit and is open only to those who qualify. There is no extra cost to you for the MTM Program.
If you qualify, we will mail you a letter. Also, you may receive a call inviting you to participate in this one-on-one medication review.
You have THREE or more of these conditions:
- Alzheimer's disease
- Bone disease—arthritis (osteoarthritis, osteoporosis, rheumatoid arthritis)
- Chronic congestive heart failure
- Diabetes
- Dyslipidemia
- End-stage renal disease
- HIV/AIDS
- Hypertension
- Mental health (depression, schizophrenia, bipolar disorder, chronic/disabling mental health conditions)
- Respiratory disease (asthma, COPD, chronic lung disorders)
MTM Program| Services Included
The MTM program enables you to participate in two review processes:
- Comprehensive Medication Review
- Targeted Medication Review
Comprehensive Medication Review
The comprehensive medication review is completed with a health care provider in person or over the phone.
It is a discussion that includes all your medications:
- Prescription drugs
- Over-the-counter (OTC)
- Herbal therapies
- Dietary supplements
This review usually takes 20 minutes or less to complete. During the review, you may ask any questions about your medications or health conditions. The health care provider may offer ways to help you manage your health and get the most out of your medications.
If more information is needed, the health care provider may contact your prescriber.
After your review, you will receive a summary of what was discussed. The summary will include the following:
- Recommended To-Do List: Your to-do list may include suggestions for you and your prescriber to discuss during your next visit.
- Medication List: This is a list of all the medications discussed during your review. You can keep this list and share it with your prescribers and/or caregivers.
Here is a blank copy of the Personal Medication List (PDF) for tracking your prescriptions.
Targeted Medication Review
The targeted medication review is completed by a health care provider who reviews your medications at least once every three months. With this review, we mail, fax, or call your prescriber with suggestions about prescription drugs that may be safer or work better for you.
As always, your prescriber will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your prescriber decide to change them.
We may also contact you by mail or phone with suggestions about your medications.
Medication Transitions
New Generations Advantage plan members may be taking drugs that aren't on our formulary (list of drugs) or that are subject to certain restrictions, such as prior authorization or step therapy. Current members may also be affected by yearly changes in our formulary.
Below is information about several options for members who are prescribed a drug that is not covered under their plan. Options include receiving a temporary supply, transitioning to a similar drug that is covered, or talking with your doctor about the change in coverage and figuring out what other options may be available to you.
Please contact Member Services if your drug is not on our formulary, is subject to certain restrictions, such as prior authorization or step therapy, or will no longer be on our formulary next year and you need help switching to a different drug that we cover or requesting a formulary exception.
Temporary Drug Supplies
During the period of time members are talking to their doctors to determine the right course of action, we may provide a temporary supply of the non-formulary drug if those members need a refill for the drug during the first 90 days of new membership in our plan.
Under certain circumstances, our plan can offer a temporary supply of a drug to a member when their drug is not on the formulary (covered drug list) or when it is restricted in some way. Doing this gives the member time to talk with their doctor about the change in coverage and figure out what to do.
The change to a member's drug coverage must be one of the following types of changes:
- The drug the member has been taking is no longer on the plan's formulary (covered drug list).
- The drug the member has been taking is now restricted in some way.
The member must be in one of the situations described below:
- Existing Plan Member NOT in a Long-Term Care Facility: For members who were part of the plan last year, we will cover a temporary supply of drug one time only during the first 90 days of the calendar year. This will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
- New Plan Member NOT in a Long-Term Care Facility: We will cover a temporary supply of your drug one time only during the first 90 days of your membership in the plan. This will be for a maximum of a 30-day supply, or less if your prescription is written for fewer days. The prescription must be filled at a network pharmacy.
- New Plan Member Currently Residing in a Long-Term Care Facility: We will cover a temporary supply of your drug during the first 90 days of your membership in the plan. The first supply will be for a maximum of a 31-day supply, or less if your prescription is written for fewer days.
- Plan Member Currently Residing in a Long-Term Care Facility Who Need a Supply Right Away: For members who have been a member of the plan for more than 90 days and are a resident of a long-term care facility, we will cover one 31-day supply, or less if your prescription is written for fewer days. This is in addition to the above long-term care transition supply.
- Plan Member Who Experience Changes in their Level of Care: If a member changes their level of care, such as a move from a hospital to a home setting, and you need a drug that is not on our formulary or if your ability to get your drugs is limited, but you are past the first 90 days of membership in our plan, we will cover up to a temporary 30-day supply (or 31-day supply if you are a long-term care resident) when you go to a network pharmacy. After your first 30-day supply, you are required to use the plan's exception process. Our transition supply will not cover drugs that Medicare does not allow Part D plans to cover, such as drugs that might be covered under Medicare Part B.
During the time when a member is getting a temporary supply of a drug, they should talk with their doctor to decide what to do when their temporary supply runs out. There may be a different drug covered by the plan that might work just as well for them. Or the member and their doctor can ask the plan to make an exception and cover the drug in the way they would like it to be covered.
Please note that our transition policy applies only to those drugs that are "Part D drugs" and bought at a network pharmacy. The transition policy can't be used to buy a non-Part D drug or a drug out-of-network, unless you qualify for out-of-network access.
For more information regarding our Transition Process, you can explore our Medication Transition Policy, or call our Medicare Prescription Drug Program at 1-888-296-6961, 24 hours a day, 7 days a week.
Have questions? We're here to help.
If you have questions about your plan, you can talk to a Member Service Representative by calling 1-866-544-7504.
Our representatives are available from 8am–8pm, seven days a week.