Pharmacy & Drugs

It's a program for Medicare Part D members to learn more about their medicines. This helps ensure safe use of medications.

If you have Medicare Part D coverage with Baylor Scott & White Health Plan, you must meet ONE of the following criteria to be eligible for MTM Services:

1. Meet ALL of the following criteria:
   A. Have at least 3 of the chronic diseases listed below.
   • Alzheimer's Disease
   • Bone disease-arthritis (including osteoporosis, osteoarthritis and rheumatoid arthritis)
   • Chronic congestive heart failure (CHF)
   • Diabetes
   • Dyslipidemia (high cholesterol)
   • End-stage renal disease (ESRD)

   • Human immunodeficiency virus/Acquired immunodeficiency syndrome (HIV/AIDS)
   • Hypertension (high blood pressure)
   • Mental Health (including depression, schizophrenia, bipolar disorder and other chronic/disabling mental health conditions)
   • Respiratory Disease (including asthma, chronic obstructive pulmonary disease (COPD) and other chronic lung diseases)
   B. Take at least 8 chronic / maintenance medications covered by your Medicare Part D plan.
   C. Be likely to spend a certain amount on Part D covered drugs each year. For 2025, you must be likely to spend $1,623.
   
   - OR -
2. Are an at-risk beneficiary (ARB) in a Drug Management Program (DMP)

There is no fee for MTM services if you meet the above criteria.

A company called Clarest Health provides the MTM services. Clarest Health has specially trained MTM providers.

1. A Comprehensive Medication Review (CMR) once per year
   • A CMR can help you learn more about your medications. This includes over the counter (OTC) products and supplements.
   • During a CMR, a qualified MTM provider talks with you and reviews your medications. The MTM provider works with you to create a plan to address any medication problems.
   • After a CMR, you will be provided a written summary. That summary will be delivered by mail and will include the following materials:
     • Cover Letter (CL)
     • Recommended To-Do List (TDL)
     • Personal Medication List (PML)
   • Where are CMR visits conducted?
     • Over the phone
   • How long is a CMR visit?
     • The time required to conduct a CMR depends on many factors. Typically, a CMR takes less than 15 min.
2. Targeted Medication Reviews (TMR) every 3 months
   • These reviews help to ensure safe use of medications. These reviews may focus on one drug or many drugs.
   • Your medications will be reviewed to see if you may be taking the targeted medication(s). If a medication problem is found during the review, your doctor will be notified. Often, this is in the form of a letter

MTM services are not a benefit for all Part D members, but are offered for free to members who qualify for the plan's MTM program.

Once you are eligible for the MTM program, you are automatically enrolled.

You will be sent a welcome letter inviting you to take part in a CMR. The letter will describe the MTM program and describe how to schedule a CMR. You may also get a phone call inviting you to schedule a CMR.

You may disenroll from the MTM program at any time. You may also refuse certain services and still stay enrolled in the MTM program. For example, you can refuse to schedule a CMR but stay in the MTM program. In this case, yourmedications would still be screened during the TMRs.

To learn more about the MTM program or to see if you are eligible for the program, call Clarest Health at 855.428.5738 8 AM to 5 PM CST.

If you do not have questions about the MTM program but have questions regarding your Medicare benefit, contact BSWHP at 866.334.3141 7 AM to 8 PM CST daily from Oct. 1 through March 31 (excluding major holidays) and on weekdays from April 1 through Sept. 30 (excluding major holidays). TTY/TDD users should call 711.

It is important to keep a list of your medications. Feel free to print and use the medication list templates below. If you take OTC medications or supplements, include these on your list too. Be sure to share your medication list with each of your healthcare providers.

• Medication List
• Medication List

This is a sign of our dedication to providing quality healthcare. Quality assurance includes measures and systems to reduce medication errors and adverse drug interactions and improve medication use.

Examples of quality assurance processes in relation to Medicare Part D may include the following:

Concurrent Drug Utilization Review

This occurs when a prescription is being filled at the pharmacy. Your prescriptions are reviewed for safety issues that may address the following:

• Possible medication errors
• Drug dosage and therapy duration errors
• Duplicate drugs that are unnecessary because you are taking another to treat the same medical condition
• Drug allergies
• Possible harmful interactions between the drugs you are taking
• Drugs that are not appropriate for your age or gender

Retrospective Drug Utilization Review

This occurs after a prescription is filled. This process reviews members' drug histories and identifies opportunities to improve the quality of care by identifying patterns of inappropriate or medically unnecessary therapy.

Drug utilization management programs are designed to improve quality and reduce costs when medically appropriate. The program includes systems to assist in preventing overuse and underuse of prescribed medications.

Examples of utilization management in relation to Medicare Part D may include the following:

Prior Authorizations & Exceptions

We require you to get prior authorization for certain drugs on formulary. This means you will need to get approval before you fill prescriptions for these drugs. If you do not get approval, the drug may not be covered by your plan. Additionally, to request coverage for a drug not listed on formulary, an exception request can be submitted.

Information about how to submit a request for prescription drug coverage or request an appeal.

Quantity Limits

For certain drugs, there are limits to the amount of the drug that we will cover. For example, we provide up to a certain number of tablets per prescription for a certain drug.

Step Therapy

In some cases, we require you to first try certain drugs to treat your medical condition before we will cover another drug for that condition. For example, if Drug A and Drug B both treat your medical condition, Baylor Scott & White Health Plan may not cover Drug B unless you try Drug A first. If Drug A does not work for you, Baylor Scott & White Health Plan will then cover Drug B.

Use of Generic Drugs

We cover both name brand and generic drugs. A generic drug has the same active ingredient as the name brand drug. Generic drugs usually cost less than name brand drugs and are approved by the Food and Drug Administration (FDA).