2013 Practitioner and Provider Manual - Presbyterian Healthcare ...

PharmacyMail Order for Medicare PlanMail order is available to all of our Medicare Part DMembers. (Specialty medications must be obtainedthrough our specialty vendor.)Medication Therapy ManagementThe Medication Therapy Management (MTM)program is designed to improve care, enhancecommunication among patients and providers,improve collaboration among providers, andoptimize medication use that leads to improvedpatient outcomes. The patient meets with aPresbyterian pharmacist for a comprehensivemedication therapy review and has additional visitswith the pharmacist throughout the year to addressongoing medication monitoring issues and eventbasedmedication therapy problems. The programis available for all members but specifically assistspeople in one of these categories:Those who take multiple prescription drugsThose who have chronic illnessesThose who expect to spend a significantamount of money on prescription drugs eachyearMTM helps to identify potential errors and gaps incare by assisting with the following:Reducing the risk of medication errors,especially for members who have chronicconditions, take several medications, or seemultiple providersProviding current information on provenmedical practices to help members and theirproviders determine the most effectivetreatmentHelping the members understand theirconditions and medications, so they can takean active role in managing their healthMTM includes five core components:Medication therapy reviewA personal medication recordA medication action planIntervention and referralDocumentation and follow-upMaximum Dosing Quantity for 30-day SupplyUnder this pharmacy benefit, a member’s 30-dayprescription supply is filled, up to the maximumdosing recommended by the manufacturer.Specialty Pharmaceuticals (Tier 5 medicationsobtained through the pharmacy benefit)Specialty pharmaceuticals are defined as high-cost(greater than $600 per 30-day supply) injectable,infused, oral, or inhaled drugs that generally requirecomplex care and supervision. These medicationsinvolve unique distribution and are usually providedby a specialty pharmacy vendor.Specialty pharmaceuticals are used to treat seriouschronic, often rare diseases. Specialtypharmaceuticals are self-administered, meaningthey are administered by the patient or to thepatient by a family member or caregiver. Somespecialty pharmaceuticals may require priorauthorization before they can be obtained. For acomplete list of specialty pharmaceuticals todetermine which require prior authorization and8-72014 Practitioner and Provider Manual - Ver. 3