Prescription drug management programs

Prescription drug management programs

Medication Therapy Management
If you are a member who takes many prescription drugs, or who has high drug costs or chronic diseases, you could be eligible for the Samaritan Advantage Health Plan HMO no-cost medication therapy management program (MTMP). Our program is designed by a team of pharmacists and physicians to ensure that you are receiving the appropriate drugs to treat your medical condition.

Program Description
Our MTM Program is designed to ensure that covered Part D drugs prescribed to targeted beneficiaries are appropriately used to optimize therapeutic outcomes through improved medication use. We also want to reduce the risk of adverse events, including adverse drug interactions for targeted beneficiaries. The program is furnished by our Clinical Pharmacist, Dr. David Engen, distinguished between ambulatory and institutional settings and is developed in cooperation with licensed and practicing pharmacists and physicians.

To qualify for MTMP, members must meet the following criteria:

  1. Must be taking a minimum of four drugs covered by Medicare Part D
  2. Must have a prescription drug spend that is greater than or equal to $3,144 per calendar year
  3. Must have a minimum of three chronic diseases that Samaritan Advantage has chosen to monitor, as permitted by CMS:
    • Alzheimer’s Disease
    • Bone Disease - Arthritis - Osteoarthritis
    • Bone Disease - Arthritis - Osteoporosis
    • Chronic Heart Failure (CHF)
    • Diabetes
    • Dyslipidemia
    • End-Stage Renal Disease (ESRD)
    • Hypertension
    • Respiratory Disease - Asthma
    • Respiratory Disease - Chronic Obstructive Pulmonary Disease (COPD)
    • Acid/Reflux/Ulcers
    • Chronic Non-cancer Pain
    • Multiple Sclerosis
Members who meet the MTMP criteria are requested to participate in the program.  Members are allowed to decline this service at any time during the contract year. During the contract year members may enroll into the MTMP if they still meet the criteria. 
The MTMP is not a benefit, but a service provided by Samaritan Advantage. Members are encouraged to contact the Plan's Customer Service department for more information.

Utilization management
For certain prescription drugs, we have additional requirements for coverage or limits on our coverage. These requirements and limits ensure that our members use these drugs in the most effective way and also help us control drug plan costs. A team of doctors and pharmacists developed these requirements and limits for our Plan to help us to provide quality coverage to our members. Examples of utilization management tools are described below:

Prior Authorization
We require you to get prior authorization for certain drugs. This means that you, your authorized representative or your provider will need to get approval from us before you fill your prescription. If they don’t get approval, we may not cover the drug.

Quantity Limits
For certain drugs we limit the amount of the drug that we will cover per prescription or for a defined period of time. For example, we will provide up to 12 doses per prescription for Zomig.

Step Therapy
In some cases, we require you to first try one drug 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, we may require your doctor to prescribe Drug A first. If Drug A does not work for you, then we will cover Drug B.

Generic Substitution
When there is a generic version of a brand-name drug available, our network pharmacies will automatically give you the generic version, unless your doctor has told us that you must take the brand-name drug.

You can find out if your drug is subject to these additional requirements or limits by looking in the formulary. If your drug does have these additional restrictions or limits, you can ask us to make an exception to our coverage rules. For further information regarding how to ask for an exception please refer to the Evidence of Coverage found under your plan page.

Other important information regarding Samaritan Advantage Health Plan's (HMO) prescription drug coverage:
See the Formulary page for a  list of covered drugs and Member Forms to request a medication exception/coverage determination.

Extra help for prescription drug costs

You may be able to get Extra Help to pay for your prescription drug premiums and costs. To see if you qualify for Extra Help, call: 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day/7 days a week; the Social Security Office at 1-800-772-1213 between 7 a.m. and 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or your State Medicaid office.

In general, beneficiaries must use network pharmacies to access their prescription drug benefit, except in non-routine circumstances. Quantity limitations and restrictions may apply.

Last modified: October 1, 2013
H3811_MA4001_2013A CMS Approved 11/06/2013