Policy:
It is the policy of the Qualexa Family of Companies (“Company”), which includes all entities administered by Qualexa as listed in the Companies in Scope section, to implement and manage a Medication Therapy Management (MTM) program in full compliance with 42 CFR 423.153(d) and all applicable CMS regulations and guidance.
Our MTM program is designed to:
- Improve medication use and adherence
- Reduce the risk of adverse events
- Optimize therapeutic outcomes for targeted beneficiaries
Goals
To achieve these goals, our MTM program:
- Ensures appropriate use of covered Part D drugs prescribed to targeted beneficiaries
- Minimizes the risk of adverse events, including adverse drug interactions
- Is provided by pharmacists or other qualified healthcare providers
- Is developed collaboratively with licensed, practicing pharmacists and physicians
- Enrolls targeted beneficiaries using an opt-out method quarterly
Minimum Services
The MTM program must offer a minimum level of services to targeted beneficiaries, including:
- Interventions for beneficiaries and prescribers
- Annual comprehensive medication review (CMR) with written summaries
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- Interactive consultation (in-person or telehealth) by a pharmacist or qualified provider
- May result in a recommended medication action plan
- If beneficiary unavailable, may be conducted with prescriber, caregiver, or authorized individual
- Quarterly targeted medication reviews with follow-up as needed
- Standardized action plans and summaries compliant with CMS requirements
- Annual information on safe disposal of controlled substance prescription drugs (from 2022)
Targeted Beneficiaries
Enrollees who meet at least one of these criteria:
- Traditional criteria (all three required):
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- Multiple chronic diseases (max 3 required for enrollment)
- Taking multiple Part D drugs (max 8 required for enrollment)
- Members must be likely to incur annual costs of $1,623 for all covered chronic Part D medications.
- At-risk beneficiaries (from January 1, 2022)
The Company annually will provide enrollees with information about safe disposal of controlled substance prescription drugs.
The Company is committed to maintaining an MTM program that meets all regulatory requirements while prioritizing the health and safety of our beneficiaries.