Medication Therapy Management (MTM) Program

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Regence offers a Medication

Therapy Management (MTM) program to

ensure you are

receiving the most effective medications, while also helping to reduce the risk of side effects

and interactions as well as your out-of-pocket costs. The program is paid in full by your plan.

This means that you can receive the benefits of the MTM program at no cost to you. There is

no change to insurance benefits, co-pays, prescription coverage, or available doctors or

pharmacies.

The MTM program is designed to help members who meet the below criteria to

get the most from their medications:

• Two or more chronic diseases including:

o

Osteoporosis

o

Rheumatoid Arthritis

o

Diabetes

o

Dyslipidemia

o

Depression

o

Asthma

o

Chronic Obstructive Pulmonary Disease (COPD)

o

Chronic Heart Failure (CHF)

o

Hypertension

o

HIV/AIDS

• Eight or more maintenance medications for chronic conditions

• Likely to incur a yearly drug spend of $3,507

Regence

members who meet the criteria will be sent an introduction letter which describes

the MTM program. Specially trained pharmacists work closely with you and your doctors to

solve any problems related to medicines and to help you get the best results. You will be

contacted by a pharmacist for an interactive person-to-person consultation to review all of

your medications and answer any questions that you may have.

Following the consultation, the pharmacist will provide you with a medication review package

which contains several helpful documents all related to your medication therapy and

consultation. A Personal Medication List template and a Medication Action Plan template are

included with this document.

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This medication list was made for you after we talked. We also used information from patient

claim data both prescription and medical, patient self-reported data including medications and

directions for use, and prescriber feedback data .

•

Use blank rows to add new medications.

Then fill in the dates you started using them.

•

Cross out medications when you no longer

use them. Then write the date and why you

stopped using them.

•

Ask your doctors, pharmacists, and other

healthcare providers in your care team to

update this list at every visit.

Keep this list up-to-date with:

[]

prescription medications

[]

over the counter drugs

[]

herbals

[]

vitamins

[]

minerals

If you go to the hospital or emergency room, take this list with you. Share this with your

family or caregivers too.

DATE PREPARED:

Allergies or side effects:

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Medication:

How I use it:

Why I use it:

Prescriber:

Notes:

Date I started using it:

Date I stopped using it:

Why I stopped using it:

Medication:

How I use it:

Why I use it:

Prescriber:

Notes:

Date I started using it:

Date I stopped using it:

Why I stopped using it:

Medication:

How I use it:

Why I use it:

Prescriber:

Notes:

Date I started using it:

Date I stopped using it:

Why I stopped using it:

, DOB:

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Medication:

How I use it:

Why I use it:

Prescriber:

Notes:

Date I started using it:

Date I stopped using it:

Why I stopped using it:

Medication:

How I use it:

Why I use it:

Prescriber:

Notes:

Date I started using it:

Date I stopped using it:

Why I stopped using it:

Medication:

How I use it:

Why I use it:

Prescriber:

Notes:

Date I started using it:

Date I stopped using it:

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Medication:

How I use it:

Why I use it:

Prescriber:

Notes:

Date I started using it:

Date I stopped using it:

Why I stopped using it:

Medication:

How I use it:

Why I use it:

Prescriber:

Notes:

Date I started using it:

Date I stopped using it:

Why I stopped using it:

Medication:

How I use it:

Why I use it:

Prescriber:

Notes:

Date I started using it:

Date I stopped using it:

Why I stopped using it:

Other Information:

If you have any questions about your medication list, call Pharmacy Services MTM Clinical

Call Center, 1-855-356-3212, Monday through Friday 7am to 7pm MST.

, DOB:

(Continued)

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This action plan will help you get the best results from your medications if you:

1. Read "What we talked about."

2. Take the steps listed in the "What I need to do" boxes.

3. Fill in "What I did and when I did it."

4. Fill in "My follow-up plan" and "Questions I want to ask."

Have this action plan with you when you talk with your doctors, pharmacists, and