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's 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
To qualify for MTMP, members must meet the following criteria:
- Must be taking a minimum of four chronic/maintenance drugs covered by Medicare Part D
- Must have a prescription drug spend that is greater than or equal to $3,000 per calendar year
- Must have a minimum of two chronic diseases that Samaritan Advantage has chosen to monitor, as permitted by CMS:
- Alzheimer’s/Dementia
- Asthma
- Cerebrovascular Disease
- COPD
- Diabetes
- Dyslipidemia
- ESRD/Renal Failure/CKD
- GI/Reflux/Ulcer Conditions
- Heart Failure
- Hypertension
- Osteoarthritis
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 on the
Member Resources page.
Other important information regarding Samaritan Advantage Health Plan's (HMO) prescription drug coverage:
See Member Resources for the
Formulary (List of Covered Drugs) and
Evidence of Coverage
Medication exception/coverage determination
Last modified: July 26, 2010
H3811_MA4001 CMS approved 11.2009