CMS Pub. 100-18, ch. 7, § 30.2

Part D sponsors are expected to target beneficiaries who:

1. Have multiple chronic diseases;

• In defining multiple chronic diseases, sponsors cannot require more than three

chronic diseases as the minimum number of multiple chronic diseases and sponsors

must target at least four of the following seven core chronic conditions:

1. Hypertension;

2. Heart Failure;

3. Diabetes;

4. Dyslipidemia;

5. Respiratory Disease (such as asthma, chronic obstructive pulmonary disease

(COPD), or chronic lung disorders;

6. Bone Disease-arthritis (such as osteoporosis, osteoarthritis, or rheumatoid

arthritis);

7. Mental Health (such as depression, schizophrenia, bipolar disorder, or

chronic and disabling disorders).

2. Are taking multiple Part D drugs; and

• In defining multiple Part D drugs, sponsors cannot require more than 8 Part D drugs

as the minimum number of multiple covered Part D drugs. Sponsors may set this

minimum threshold at any number equal to or between two and eight.

3. Are likely to incur annual costs for covered Part D drugs that exceed a predetermined

level as specified by the Secretary.

• For CY 2010 the cost threshold will be $3000, and sponsors’ targeting criteria

should be adjusted accordingly.

Sponsors are required to target beneficiaries for enrollment at least quarterly during the year to

allow more Medicare beneficiaries to have access to the MTM program earlier in the year. For

example, daily, weekly, monthly, or quarterly targeting frequencies would meet this requirement.

However, CMS also expects Part D sponsors to promote continuity of care by performing an

end-of-year analysis that identifies current MTM program participants who will continue to meet

the eligibility criteria for the next program year for the same plan. This targeting could be done

to auto-enroll eligible beneficiaries in the plan’s MTM program early in the next program year

in order to provide MTM interventions with less interruption.

Additionally, sponsors are required to enroll targeted beneficiaries into MTM programs using

only an opt-out method. A beneficiary that meets the targeting criteria would be auto-enrolled

and considered to be enrolled unless he/she declines enrollment. The enrolled beneficiaries may

refuse or decline individual services without having to disenroll from the program. This

requirement will allow Medicare beneficiaries to have more access to MTM services and

increase member compliance and enrollment into these programs. Part D sponsors are reminded

that if an enrollee chooses to opt-out of the plan’s MTM program, they must continue to apply

their existing drug utilization management program to ensure the beneficiary receives high

quality prescription drug coverage.

Although plans decide how potential providers of MTM services are informed of MTM qualified

beneficiaries, CMS envisions that the most common method for identifying targeted

beneficiaries to individuals responsible for providing the services (e.g., pharmacists), will be

system edits, computerized notices that appear on the pharmacists’ computer when a beneficiary

fills a prescription. CMS expects that sponsors and pharmacists will coordinate these edits as

part of the terms and conditions of their contracts. Therefore, Part D sponsors need to develop

appropriate mechanisms for identifying and notifying targeted beneficiaries who are eligible for

MTMP services.

Should an enrollee desire to permanently opt-out of the plan’s MTM program, the plan should

honor the request and not re-target the beneficiary in future contract years; however, if the

enrollee actively seeks enrollment into the MTMP at a later time, perhaps due to a level of care

change, the plan must allow the enrollee to participate as long as he or she meet the necessary

MTMP requirements.

Although participation in MTMPs is voluntary for beneficiaries, CMS hopes they will participate

to improve their therapeutic outcomes. Beneficiaries must not be denied access to prescription

drugs based upon failure to participate in MTMPs.