Medication Therapy Management: A Part D Plan Program to Benefit Your Clients

The annual enrollment period for Medicare Part D plans will be here before you know it. While prescription drug plans are just one piece of a health insurance package. Your knowledge of specific features of these prescription drug plans – beyond Rx coverage, premiums and co-pays ­– could be extremely valuable to your clients and their health. That’s especially true when it comes to the many older adults living with ongoing health conditions who are taking a multitude of different medications.

The numbers are striking, and on the rise, given our aging population. In fact, six in ten older adults have at least two chronic health conditions; over 40% take five or more prescription drugs and nearly one in five are prescribed more than 10 medications. Not only can multiple prescriptions mean high out-of-pocket costs for your clients, but they also raise the risks of medication-related adverse events which cause as many as 30% of hospital admissions among the senior population.

That is why it’s important to talk to your eligible clients about Medication Therapy Management (MTM), a free program offered by Part D plans that can help lead to better medication safety and effectiveness, as well as lower enrollees’ costs. Sharing that knowledge with your clients -- and helping them save on their prescription drugs – should improve client satisfaction and retention.

What does MTM do for Part D beneficiaries?

The Centers for Medicare and Medicaid Services (CMS) requires all Medicare prescription drug plans provide an MTM program to help ensure eligible beneficiaries are being prescribed the most effective medications and are taking them properly to prevent medication-related problems and improve drug adherence. Additionally, MTM programs can help reduce prescription drug costs for enrollees.

MTM programs include an annual in-person or telephonic consultation with a pharmacist or qualified health provider in which a comprehensive medication review (CMR) is performed at no extra cost to the beneficiary.  The session involves assessing all prescription drugs, OTC medications, herbal therapies and dietary supplements the beneficiary is using and addressing their questions and concerns. If medication-related issues are identified, a plan is developed to resolve the problem with the patient, caregiver and/or prescriber. For Humana’s Part D members, the CMR can help determine if there are generic or alternative medications that could help beneficiaries save on out-of-pocket costs.

MTM programs are voluntary; if a beneficiary qualifies, the Part D plan will contact the individual to invite them to participate in the program. For clients you think may be eligible, it could be helpful to explain the benefits of these programs and encourage them to participate. The value of the MTM program was shown in a study by Humana that found MTM services reduce inpatient hospital admissions and emergency room, urgent care and physician visits, as well as lower overall medical costs for those participating in the program for the first time. Another study showed a medication problem was identified through an MTM program in 85% of participating patients and 93.3% of patients felt their overall health and well-being improved because of MTM services.

Who qualifies for MTM?

While all Part D plans offer MTM programs, there can be differences in the eligibility criteria from one plan to another.

To be eligible for MTM, beneficiaries must meet all three of the following:

• They must have at least three chronic diseases. While CMS provides a list of health conditions, five of which must be included in every plan’s MTM eligibility criteria, each plan can decide which of those diseases to include and can also add others.
• They must be taking two to eight chronic/maintenance drugs offered by the Part D plan per CMS. Each plan determines the exact number.
• Their annual Part D medication costs (both what the plan pays and any copays or coinsurance) for 2024 are likely to be $5,330 or more.

Since Part D plans can require MTM eligibility based on different chronic diseases, it’s important to consider not only your client’s medications, but also their health conditions when recommending a Part D plan.

Since health circumstances can change, beneficiaries must requalify for MTM programs each year. If you have a new or current client you think is eligible for MTM, talking to them about the program and encouraging their participation is not only good for them, it also could be good for your business.

To learn more about Humana's MTM programs, click here.