Medication Therapy Management Program

The Clover Health Medication Therapy Management (MTM) program helps you get the greatest health benefit from your medications by preventing or reducing drug-related risks, increasing your awareness, and supporting good habits.

Who qualifies for the MTM program?

We will automatically enroll you in the Clover Health Medication Therapy Management Program at no cost to you if:

A. All three of these conditions apply:

1. You are in a PPO or HMO plan and take eight or more Medicare Part D covered maintenance drugs
2. You have three or more of these long term health conditions:
   • 2024
     • COPD
     • Diabetes
     • Depression
     • Alzheimer's Disease
     • Chronic Heart Failure
     • HIV/AIDS
     • High Blood Pressure
     • High Cholesterol
   • 2025
     • COPD
     • Diabetes
     • Depression
     • Alzheimer's Disease
     • Chronic Heart Failure
     • HIV/AIDS
     • High Blood Pressure
     • High Cholesterol
     • Arthritis
     • ESRD
3. You reach the following in yearly prescription drug costs paid by you and the plan:
   • 2024: $5,330
   • 2025: $1,623

B.  If you are an at-risk beneficiary (ARB) under a Drug Management Program (DMP), you will automatically be enrolled in the Clover Health Medication Therapy Management program at no cost to you. ARBs may be defined as having use of opioids with an average daily morphine milligram equivalent (MME) equal to or exceeding 90 mg for any duration during the most recent 6 months and use of multiple opioid prescribers and multiple dispensing pharmacies.

Your participation is voluntary and does not affect your coverage. This program is free of charge and is open only to those who qualify. The MTM program is not considered a benefit for all members.

What services are included in the MTM program?

The MTM Program provides you with a:

• Comprehensive Medication Review (CMR)
• Targeted Medication Review (TMR)

What's a Comprehensive Medication Review (CMR)?

A CMR is a one-on-one discussion with a pharmacist, to answer questions and address concerns you have about the medications you take, including:

• Prescription drugs
• Over-the-counter (OTC) medicines
• Herbal therapies
• Dietary supplements and vitamins

The pharmacist will offer ways to manage your conditions with the drugs you take. If more information is needed, the pharmacist may contact your prescribing doctor. A CMR takes about 30 minutes and is usually offered once each year—if you qualify. At the end of your discussion, the pharmacist will give you a Medication List for the medications discussed during your CMR.

You will also receive a Recommended To-Do List. Your plan may include suggestions from the pharmacist for you and your doctor to discuss during your next doctor visit.

If you'd like, you can track your prescriptions in a medication list.

What's a Targeted Medication Review (TMR)?

We perform a TMR by mailing or faxing suggestions to your doctor every three months about prescription drugs that may be safer or work better than your current drugs. As always, your prescribing doctor will decide whether to consider our suggestions. Your prescription drugs will not change unless you and your doctor decide to change them.

How will I know if I qualify for the MTM program?

If you qualify, we will mail you a letter letting you know that you qualify for the MTM program. Afterward, you may receive a call from a partner pharmacy inviting you to schedule a one-on-one medication review (by phone or in person).

Will the MTM program pharmacist be calling from my regular pharmacy?

Yes, the MTM program pharmacist may be calling from your regular pharmacy if your regular pharmacy chooses to participate in the MTM Program as a service provider. You will be given the option to choose an in-person review or a phone review.

If your regular pharmacy does not participate in the program, you may be contacted by a call center pharmacist. They’ll provide your MTM review and ensure that you have access to the service if you want to participate. Call center reviews are conducted by phone.

Why is a review with a pharmacist important?

Different doctors may write prescriptions for you without knowing all the prescription drugs and/or OTC medications you take. For that reason, a pharmacist will:

• Discuss how your prescription drugs and OTC medications may affect each other.
• Identify any prescription drugs and OTC medications that may cause side effects, and offer suggestions to help.
• Help you get the most benefit from all of your prescription drugs and OTC medications.
• Review opportunities to help you reduce your prescription drug costs.

How do I benefit from talking with a pharmacist?

Different doctors may write prescriptions for you without knowing all the prescription drugs and/or OTC medications you take. For that reason, a pharmacist will:

• Discuss your medications to give you peace of mind knowing that you are taking your prescription drugs and OTC medications safely
• Give you a Medication List to keep and share with your doctors and healthcare providers

How can I get more information about the MTM program, and what if I don't want to participate at all?

If you would like additional information about this program or you do not wish to take part in the MTMP, call us toll-free at 1-866-978-0510, Mon - Thur 9am - 7pm, Fri 9am - 5pm, and Sat 9am-1pm (Eastern Standard Time). If you have a hearing impairment, please dial National Relay Service number 711.