MTM Administration & Management
Eligibility
CMS requires Part D sponsors to offer an MTM program to targeted beneficiaries who meet all three criteria: multiple chronic diseases drawn from the CMS-specified list (for example diabetes, heart failure, hypertension, dyslipidemia, COPD, arthritis, Alzheimer's disease, end-stage renal disease, and mental health disorders), multiple covered Part D drugs, and expected annual drug costs above a threshold CMS reindexes each year. Do not memorize a dollar figure as permanent. Enrollment is voluntary - a beneficiary may decline - and the plan must give annual notice of the program.
Required elements
The centerpiece is the comprehensive medication review, an interactive discussion with the beneficiary or caregiver that produces two written outputs: the personal medication list (what the patient actually takes) and the medication action plan (what the patient agrees to do). Programs must also document the encounter, make prescriber interventions and referrals, and provide follow-up.
Traps
Question writers swap the personal medication list and the medication action plan, imply the pharmacist can unilaterally change therapy (pharmacists recommend; prescribers authorize), or state that enrollment is automatic once criteria are met.
Rule of thumb
The list is the personal medication list; the to-do list is the medication action plan; the conversation that produces both is the comprehensive medication review. When a question asks what happens first for a newly eligible member, the answer is outreach, consent, and scheduling - not a therapy change.