CMS Pub. 100-18, ch. 7, § 30.6

Each Part D sponsor is required to incorporate an MTMP into its plans’ benefit structure.

Annually, all Part D sponsors, including renewing sponsors and new applicants, must submit an

MTMP description to CMS for review and approval. A CMS-approved MTMP is one of several

required elements in the development of sponsors’ bids for a contract year.

MA Private Fee for Service (MA-PFFS) organizations, as described in 42 CFR 422.4 (a)(3), are

not required to have an MTMP. However, given that MA-PFFS organizations have an equal

responsibility to provide a quality Part D product, CMS encourages MA-PFFS organizations to

establish MTMPs to improve quality for their enrollees and to submit their program to CMS for

review. [NOTE: MTMPs offered by MA-PFFS organizations should meet the same standards as

other Part D MTMPs.]

The MTMP submission should be submitted through the Health Plan Management System

(HPMS) in the MTMP module. This interface was established to enable Part D sponsors to

enter, edit, and submit their MTMP descriptions within HPMS at the contract level. The

submitted MTMP descriptions should be as detailed as possible and an MTMP submission

template is provided as a guide to facilitate the submission process. This memorandum is

updated annually and posted on the MTMP Web page (see Appendix A).

CMS will communicate with each sponsor regarding the status of their MTMP review (including

if the MTMP requires resubmission to correct deficiencies or if the MTMP meets all of the

minimum requirements for the contract year). Communications will be sent via email to the

HPMS MTMP Main Contact and Medicare Compliance Officer. Sponsors should ensure that

their contact information is up-to-date in HMPS under the Contract Management section.

If a Part D sponsor needs to submit an MTMP outside of the initial submission upload and

resubmission processes, it should email a request to have the submission gate opened to

partd_mtm@cms.hhs.gov. The following represents information that sponsors are required to

submit as part of their MTMP applications.

Information that MUST be included with the MTMP Application

• Criteria #1: Multiple Chronic Diseases

o Provide the minimum number of chronic diseases a beneficiary must have to meet

this criterion. (NOTE: the definition of multiple is any number of two or more)

o Provide the specific name of each chronic disease that applies or if any chronic

disease applies.

o Example 1: A beneficiary must have any two or more chronic diseases.

o Example 2: A beneficiary must have two or more chronic diseases. The following

chronic diseases will be targeted: Respiratory Disease-asthma, Respiratory

Disease-COPD, Bone Disease-arthritis-rheumatoid arthritis, dyslipidemia,

Mental Health-depression, autoimmune disorders, HIV/AIDS.

• Criteria #2: Multiple Covered Part D Drugs

o Provide the minimum number of covered Part D drugs that a beneficiary must

have filled to meet this criterion. (NOTE: the definition of multiple is any number

of two or more)

o Provide the type of covered Part D drugs that applies (i.e., any Part D drug,

chronic/ maintenance drugs, disease-specific, specific Part D drug classes).

○ Example 1: A beneficiary must have filled any five or more distinct covered Part

D drugs.

○ Example 2: A beneficiary must have filled any two or more distinct covered Part

D chronic/maintenance drugs.

• Criteria #3: Are likely to incur annual costs for covered Part D drugs that exceed a

predetermined level as specified by the Secretary.

o Provide a detailed description of the analytical procedure used to determine if a

beneficiary is likely to incur annual costs in excess of a predetermined level as

specified by the Secretary for all covered Part D drugs.

o Example 1: Provide the monthly or quarterly dollar threshold per beneficiary for

covered Part D drugs (the specific threshold should be provided).

o Example 2: Describe the predictive model used to identify beneficiaries who are

likely to incur this annual cost.

• Procedure and frequency of identifying beneficiaries

o Provide the frequency of identifying beneficiaries which is required to be no less

frequently than quarterly. For example, daily, weekly, monthly or quarterly

targeting frequencies should meet this requirement.

o Describe the data evaluated for targeting eligible beneficiaries. Examples include

drug claims, medical claims, lab data, etc.

• Methods of enrollment and disenrollment. Sponsors are required to enroll targeted

beneficiaries using an opt-out model.

• Type, frequency and recipient of interventions.

o Provide the recipient of MTM interventions. This will automatically default to

beneficiary and prescriber. Other recipients may also be provided.

o Provide the specific beneficiary interventions;

• This will automatically default to review of medications, interactive,

person-to-person consultation, and individualized, written summary of the

interactive consultation.

• Selections must be provided for the delivery method(s) for the interactive

consultation and the type(s) of written takeaways.

• Targeted medication reviews at least quarterly will also be an automatic

default.

• Additionally, other beneficiary interventions may be provided.

o Provide the specific prescriber interventions:

• This will automatically default to prescriber interventions to resolve

medication-related problems or optimize therapy.

• Selections must be provided for the delivery method(s) for the prescriber

consultation.

• Additionally, other prescriber interventions may be provided.

o Provide a detailed description of how your program will provide the MTM

interventions for both beneficiaries and prescribers, including the annual

comprehensive medication review for the beneficiary, which includes a review of

medications, interactive, person-to-person consultation, and an individualized,

written summary of interactive consultation, and quarterly targeted medication

reviews.

• Resources and who will provide MTM services.

o Provide the type of personnel that will be providing the MTM services such as in-house staff or the type of outside personnel.

o Provide the type of qualified provider such as pharmacist, physician, or

registered nurse.

• How fees will be established for MTMP if using outside personnel. If establishing fees

for pharmacists or others, provide the amount of fee respective to MTMP management

and the fee paid for the provider of the MTM.

o Provide if fees are covered as part of the services of the global Pharmacy Benefits

Manager (PBM) or vendor contract (without being priced out separately) or if

fees are priced out separately.

o If the fees are priced out separately and the plan is charged a fee by the PBM or

vendor within the contract, then a description of the specific fees needs to be

reported.

• Provide the specific fee(s), billing method(s) such as per minute or per

service. A description of these fees may also be included.

• Methods of documenting and measuring outcomes.

Provide the outcomes measured.