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![Page 1: D ] ] } vd Z ÇD v P u v W } P u...Asuris Medication Therapy Management Program Author Asuris Northwest Health Subject Asuris Medication Therapy Management Program Keywords Medication,](https://reader033.vdocument.in/reader033/viewer/2022042204/5ea5d3a9f8a8eb183b7c68dd/html5/thumbnails/1.jpg)
Medication Therapy Management Program
The Medication Therapy Management (MTM) Program helps you get the best results with your medications while keeping your costs down Through MTM a pharmacist will review all your medications and provide the extra attention you need to keep your medications on the right track The MTM program is provided at no additional cost to you and is not considered a benefit
MTM Services
Through the MTM program you may receive the following services
Comprehensive Medication Review (CMR) A pharmacist will meet with you face-to-face or via phone to review all your medications for
problems and help to organize your medication schedule They may also recommend lower cost alternatives to your medications
Following the CMR you will receive a Medication Action Plan and Personal Medication List Estimated Time to Complete 15 -30 minutes
Targeted Medication Review (TMR) Your medications will be reviewed every 3 months to look for any serious concerns related
to your medications A pharmacist will reach out to you if a serious concern is found
Prescriber Consult A pharmacist will work with your doctor(s) to resolve any concerns or problems found with
your medications
How to Join
First you must qualify for MTM by meeting all 3 of the following
1 You have a total drug cost of over $4255 a year 2 You take 8 or more long term medications 3 You have at least 3 of the following long-term diseases
o Heart Failure o Diabetes o High Cholesterol o High Blood Pressure o Osteoporosis o Rheumatoid Arthritis o Asthma o COPD (Chronic Obstructive Pulmonary Disease) o HIVAIDS o Depression
If you qualify we will contact you by mail An MTM Personal Pharmacist may also contact you at your pharmacy or by phone To get started or if you have questions call 1-800-541-8981 Ask about the locations of MTM Personal Pharmacists in your area
Joining the MTM program is voluntary Keep in mind that the program is helpful in
preventing side effects helping you save money making sure your medications are safe and are working well for you
As your health changes you may want a pharmacist to review your medications If you decide to opt out of this helpful service you may call 1-800-541-8981
Frequently Asked Questions
Where can I find a pharmacist who provides these MTM services Call us at 1-800-541-8981 or visit httpoutcomesmtmcom
Who are the MTM Personal Pharmacists MTM Personal Pharmacists may be a pharmacist at your local pharmacy a pharmacist at your doctors office or a pharmacist we contract with
Are all pharmacists in the Asuris network also MTM pharmacists Not all pharmacists in the Asuris pharmacy network provide MTM services Our MTM Personal Pharmacists have completed special training to provide these extra services
Can I use my regular pharmacy and still visit an MTM pharmacist too Yes MTM services are an added value of membership You may continue to use any Asuris participating pharmacy for your prescriptions
Can a pharmacist save me money Yes Similar medications may be available at lower costs Your pharmacist can help you look for less costly medications
Will my doctor know if any changes need to be made to my prescriptions Yes Your pharmacist may make recommendations to you and your doctor(s) ndash but only your doctor can change your prescription
Will I be required to use an MTM pharmacist No MTM services through a specially trained pharmacist are an added service of membership They are there to help but you are not required to use them
A pharmacist from Cardinal Health called me Is that different from Asuris Cardinal Health pharmacists are contracted with Asuris to provide MTM services when you are unable to receive MTM services at your pharmacy These pharmacists can also help you with getting the best results from your medications
lt MTM PROVIDER HEADER or OPTIONAL LOGO gt
lt MTM PROVIDER HEADER or OPTIONAL LOGOgt
I PERSONAL MEDICATION LIST FORlt Insert Members name DOB mmddyyyy gt
This medication list was made for you after we talked We also used information fromlt insert sources of iriformation gt
bull Use blank rows to add new medications Then fill in the dates you started using them
Keep this list up-to-date with
prescription medications bull Cross out medications when you no
longer use them Then write the date and why you stopped using them
over the counter drugs
bull Ask your doctors pharmacists and other healthcare providers in your care team to update this list at every visit
herbals vitamins minerals
If you go to the hospital or emergency room take this list with you with your family or caregivers too
Share this
DATEPREPAREDltINSERTDATEgt Allergies or side effects lt Insert beneficiarys allergies and adverse drug reactions including the medications and their effects gt
Medication lt Insert generic name and brand name strength and dosage form for currentactive medicationsgt How I use it lt Insert regimen including strength dose and frequency (eg 1 tablet (20 mg) by mouth daily) use of related devices and supplemental instructions as appropriate gt Why I use it lt Insert indication or Prescriber lt Insert prescribers name intended medical use gt gt lt Insert other title(s) or delete this fieldgt lt Use for optional product-related iriformation such as additional instructions product imageidentifiers goals of therapy pharmacy etc and change field title accordingly This field may be expanded or divided Delete this field if not used gt Date I started using it lt May be Date I stopped using it lt Leave blank estimated by Plan or entered based for beneficiary to enter stop date gt upon beneficiary-reported data or leave blank for beneficiary to enter start date gt Why I stopped using it lt Leave blank for beneficiarys notesgt
Form CMS-10396 (0817) Form Approved 0MB No 0938-1154
Page 1 of3
I PERSONAL MEDICATION LIST FORlt Insert Members name DOB mmddyyyy gt (Continued)
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this_field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this fieldgt Date I started using it I Date I stopped using it Why I stopped usin2 it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this_field gt Date I started usin2 it I Date I stopped usin2 it Why I stopped using it
Form CMS-10396 (0817) Form Approved 0MB No 0938-1154
Page 2 of3
I PERSONAL MEDICATION LIST FORlt Insert Members name DOB mmddyyyy gt (Continued)
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this_field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Other Information
If you have any questions about your medication list call lt insert MTM provider contact information phone numbers daystimes etc gt
According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid 0MB control number The valid 0MB number for this information collection is 0938-1154 The time required to complete this information collection is estimated to average 40 minutes per response including the time to review instructions searching existing data resources gather the data needed and complete and review the information collection If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form please write to CMS Attn PRA Reports Clearance Officer 7500 Security Boulevard Baltimore Maryland 21244-1850
Form CMS-10396 (0817) Form Approved 0MB No 0938-1154
Page 3 of3
- MTM Website Content_ASURIS_20190816
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![Page 2: D ] ] } vd Z ÇD v P u v W } P u...Asuris Medication Therapy Management Program Author Asuris Northwest Health Subject Asuris Medication Therapy Management Program Keywords Medication,](https://reader033.vdocument.in/reader033/viewer/2022042204/5ea5d3a9f8a8eb183b7c68dd/html5/thumbnails/2.jpg)
If you qualify we will contact you by mail An MTM Personal Pharmacist may also contact you at your pharmacy or by phone To get started or if you have questions call 1-800-541-8981 Ask about the locations of MTM Personal Pharmacists in your area
Joining the MTM program is voluntary Keep in mind that the program is helpful in
preventing side effects helping you save money making sure your medications are safe and are working well for you
As your health changes you may want a pharmacist to review your medications If you decide to opt out of this helpful service you may call 1-800-541-8981
Frequently Asked Questions
Where can I find a pharmacist who provides these MTM services Call us at 1-800-541-8981 or visit httpoutcomesmtmcom
Who are the MTM Personal Pharmacists MTM Personal Pharmacists may be a pharmacist at your local pharmacy a pharmacist at your doctors office or a pharmacist we contract with
Are all pharmacists in the Asuris network also MTM pharmacists Not all pharmacists in the Asuris pharmacy network provide MTM services Our MTM Personal Pharmacists have completed special training to provide these extra services
Can I use my regular pharmacy and still visit an MTM pharmacist too Yes MTM services are an added value of membership You may continue to use any Asuris participating pharmacy for your prescriptions
Can a pharmacist save me money Yes Similar medications may be available at lower costs Your pharmacist can help you look for less costly medications
Will my doctor know if any changes need to be made to my prescriptions Yes Your pharmacist may make recommendations to you and your doctor(s) ndash but only your doctor can change your prescription
Will I be required to use an MTM pharmacist No MTM services through a specially trained pharmacist are an added service of membership They are there to help but you are not required to use them
A pharmacist from Cardinal Health called me Is that different from Asuris Cardinal Health pharmacists are contracted with Asuris to provide MTM services when you are unable to receive MTM services at your pharmacy These pharmacists can also help you with getting the best results from your medications
lt MTM PROVIDER HEADER or OPTIONAL LOGO gt
lt MTM PROVIDER HEADER or OPTIONAL LOGOgt
I PERSONAL MEDICATION LIST FORlt Insert Members name DOB mmddyyyy gt
This medication list was made for you after we talked We also used information fromlt insert sources of iriformation gt
bull Use blank rows to add new medications Then fill in the dates you started using them
Keep this list up-to-date with
prescription medications bull Cross out medications when you no
longer use them Then write the date and why you stopped using them
over the counter drugs
bull Ask your doctors pharmacists and other healthcare providers in your care team to update this list at every visit
herbals vitamins minerals
If you go to the hospital or emergency room take this list with you with your family or caregivers too
Share this
DATEPREPAREDltINSERTDATEgt Allergies or side effects lt Insert beneficiarys allergies and adverse drug reactions including the medications and their effects gt
Medication lt Insert generic name and brand name strength and dosage form for currentactive medicationsgt How I use it lt Insert regimen including strength dose and frequency (eg 1 tablet (20 mg) by mouth daily) use of related devices and supplemental instructions as appropriate gt Why I use it lt Insert indication or Prescriber lt Insert prescribers name intended medical use gt gt lt Insert other title(s) or delete this fieldgt lt Use for optional product-related iriformation such as additional instructions product imageidentifiers goals of therapy pharmacy etc and change field title accordingly This field may be expanded or divided Delete this field if not used gt Date I started using it lt May be Date I stopped using it lt Leave blank estimated by Plan or entered based for beneficiary to enter stop date gt upon beneficiary-reported data or leave blank for beneficiary to enter start date gt Why I stopped using it lt Leave blank for beneficiarys notesgt
Form CMS-10396 (0817) Form Approved 0MB No 0938-1154
Page 1 of3
I PERSONAL MEDICATION LIST FORlt Insert Members name DOB mmddyyyy gt (Continued)
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this_field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this fieldgt Date I started using it I Date I stopped using it Why I stopped usin2 it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this_field gt Date I started usin2 it I Date I stopped usin2 it Why I stopped using it
Form CMS-10396 (0817) Form Approved 0MB No 0938-1154
Page 2 of3
I PERSONAL MEDICATION LIST FORlt Insert Members name DOB mmddyyyy gt (Continued)
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this_field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Other Information
If you have any questions about your medication list call lt insert MTM provider contact information phone numbers daystimes etc gt
According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid 0MB control number The valid 0MB number for this information collection is 0938-1154 The time required to complete this information collection is estimated to average 40 minutes per response including the time to review instructions searching existing data resources gather the data needed and complete and review the information collection If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form please write to CMS Attn PRA Reports Clearance Officer 7500 Security Boulevard Baltimore Maryland 21244-1850
Form CMS-10396 (0817) Form Approved 0MB No 0938-1154
Page 3 of3
- MTM Website Content_ASURIS_20190816
- PML
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![Page 3: D ] ] } vd Z ÇD v P u v W } P u...Asuris Medication Therapy Management Program Author Asuris Northwest Health Subject Asuris Medication Therapy Management Program Keywords Medication,](https://reader033.vdocument.in/reader033/viewer/2022042204/5ea5d3a9f8a8eb183b7c68dd/html5/thumbnails/3.jpg)
lt MTM PROVIDER HEADER or OPTIONAL LOGO gt
lt MTM PROVIDER HEADER or OPTIONAL LOGOgt
I PERSONAL MEDICATION LIST FORlt Insert Members name DOB mmddyyyy gt
This medication list was made for you after we talked We also used information fromlt insert sources of iriformation gt
bull Use blank rows to add new medications Then fill in the dates you started using them
Keep this list up-to-date with
prescription medications bull Cross out medications when you no
longer use them Then write the date and why you stopped using them
over the counter drugs
bull Ask your doctors pharmacists and other healthcare providers in your care team to update this list at every visit
herbals vitamins minerals
If you go to the hospital or emergency room take this list with you with your family or caregivers too
Share this
DATEPREPAREDltINSERTDATEgt Allergies or side effects lt Insert beneficiarys allergies and adverse drug reactions including the medications and their effects gt
Medication lt Insert generic name and brand name strength and dosage form for currentactive medicationsgt How I use it lt Insert regimen including strength dose and frequency (eg 1 tablet (20 mg) by mouth daily) use of related devices and supplemental instructions as appropriate gt Why I use it lt Insert indication or Prescriber lt Insert prescribers name intended medical use gt gt lt Insert other title(s) or delete this fieldgt lt Use for optional product-related iriformation such as additional instructions product imageidentifiers goals of therapy pharmacy etc and change field title accordingly This field may be expanded or divided Delete this field if not used gt Date I started using it lt May be Date I stopped using it lt Leave blank estimated by Plan or entered based for beneficiary to enter stop date gt upon beneficiary-reported data or leave blank for beneficiary to enter start date gt Why I stopped using it lt Leave blank for beneficiarys notesgt
Form CMS-10396 (0817) Form Approved 0MB No 0938-1154
Page 1 of3
I PERSONAL MEDICATION LIST FORlt Insert Members name DOB mmddyyyy gt (Continued)
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this_field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this fieldgt Date I started using it I Date I stopped using it Why I stopped usin2 it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this_field gt Date I started usin2 it I Date I stopped usin2 it Why I stopped using it
Form CMS-10396 (0817) Form Approved 0MB No 0938-1154
Page 2 of3
I PERSONAL MEDICATION LIST FORlt Insert Members name DOB mmddyyyy gt (Continued)
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this_field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Other Information
If you have any questions about your medication list call lt insert MTM provider contact information phone numbers daystimes etc gt
According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid 0MB control number The valid 0MB number for this information collection is 0938-1154 The time required to complete this information collection is estimated to average 40 minutes per response including the time to review instructions searching existing data resources gather the data needed and complete and review the information collection If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form please write to CMS Attn PRA Reports Clearance Officer 7500 Security Boulevard Baltimore Maryland 21244-1850
Form CMS-10396 (0817) Form Approved 0MB No 0938-1154
Page 3 of3
- MTM Website Content_ASURIS_20190816
- PML
-
![Page 4: D ] ] } vd Z ÇD v P u v W } P u...Asuris Medication Therapy Management Program Author Asuris Northwest Health Subject Asuris Medication Therapy Management Program Keywords Medication,](https://reader033.vdocument.in/reader033/viewer/2022042204/5ea5d3a9f8a8eb183b7c68dd/html5/thumbnails/4.jpg)
I PERSONAL MEDICATION LIST FORlt Insert Members name DOB mmddyyyy gt (Continued)
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this_field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this fieldgt Date I started using it I Date I stopped using it Why I stopped usin2 it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this_field gt Date I started usin2 it I Date I stopped usin2 it Why I stopped using it
Form CMS-10396 (0817) Form Approved 0MB No 0938-1154
Page 2 of3
I PERSONAL MEDICATION LIST FORlt Insert Members name DOB mmddyyyy gt (Continued)
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this_field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Other Information
If you have any questions about your medication list call lt insert MTM provider contact information phone numbers daystimes etc gt
According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid 0MB control number The valid 0MB number for this information collection is 0938-1154 The time required to complete this information collection is estimated to average 40 minutes per response including the time to review instructions searching existing data resources gather the data needed and complete and review the information collection If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form please write to CMS Attn PRA Reports Clearance Officer 7500 Security Boulevard Baltimore Maryland 21244-1850
Form CMS-10396 (0817) Form Approved 0MB No 0938-1154
Page 3 of3
- MTM Website Content_ASURIS_20190816
- PML
-
![Page 5: D ] ] } vd Z ÇD v P u v W } P u...Asuris Medication Therapy Management Program Author Asuris Northwest Health Subject Asuris Medication Therapy Management Program Keywords Medication,](https://reader033.vdocument.in/reader033/viewer/2022042204/5ea5d3a9f8a8eb183b7c68dd/html5/thumbnails/5.jpg)
I PERSONAL MEDICATION LIST FORlt Insert Members name DOB mmddyyyy gt (Continued)
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this_field gt Date I started using it I Date I stopped using it Why I stopped using it
Medication How I use it Why I use it I Prescriber lt Insert other title(s) or delete this field gt Date I started using it I Date I stopped using it Why I stopped using it
Other Information
If you have any questions about your medication list call lt insert MTM provider contact information phone numbers daystimes etc gt
According to the Paperwork Reduction Act of 1995 no persons are required to respond to a collection of information unless it displays a valid 0MB control number The valid 0MB number for this information collection is 0938-1154 The time required to complete this information collection is estimated to average 40 minutes per response including the time to review instructions searching existing data resources gather the data needed and complete and review the information collection If you have any comments concerning the accuracy of the time estimate(s) or suggestions for improving this form please write to CMS Attn PRA Reports Clearance Officer 7500 Security Boulevard Baltimore Maryland 21244-1850
Form CMS-10396 (0817) Form Approved 0MB No 0938-1154
Page 3 of3
- MTM Website Content_ASURIS_20190816
- PML
-