We conduct drug utilization reviews for all of our members to make sure that they are getting safe and appropriate care. These reviews are especially important for members who have more than one doctor who prescribes their medications. We conduct drug utilization reviews each time you fill a prescription and on a regular basis by reviewing our records. During these reviews, we look for medication problems such as:
Medication Therapy Management (MTM) Program Through the Horizon Blue Cross Blue Shield of New Jersey ("Horizon BCBSNJ") Medication Therapy Management ("MTM") program, Horizon BCBSNJ identifies members who might be at risk for a medical or drug adverse event and works with physicians and members to reduce that possibility. The MTM program encourages members to use medications according to national clinical guidelines, and to take their medications appropriately and in accordance with their physicians' instructions.
How are members selected to participate in the Horizon BCBSNJ MTM program? Members are identified for eligibility in the MTM program using their prescription drug claims history as outlined by the Centers for Medicare & Medicaid Services ("CMS"). Eligible members who meet the criteria below are enrolled in the MTM program, however, they may "opt out" of the program at any time. The member may opt out by calling the Horizon BCBSNJ member services number located on the back of their ID card.
Members must meet ALL three of the following criteria to be eligible for the MTM program.
1. Members must have at least two chronic diseases from the following list:
2. Members must be taking at least five covered Part D drugs per month.
3. Members must have incurred costs for covered Part D drugs in either of the following amounts: at least $4,000 annually or at least $1,000 per quarter.
What activities occur in the Horizon BCBSNJ MTM program?
1. Physician communicationsHorizon BCBSNJ pharmacists conduct routine medication profile reviews and, upon identifying a medication issue, contact the physician to discuss the issue. Examples of medication issues may include the use of multiple drugs to treat the same condition, dosage of medications and drug-drug interactions.
2. Member communicationsHorizon BCBSNJ pharmacists conduct routine medication profile reviews and, upon identifying a medication issue, contact the member either by telephone or by mail to address the medication issue. As noted in the paragraph above, the member's physician is also contacted.
3. Member newslettersA quarterly newsletter will be sent to all Horizon Medicare Advantage members with Part D coverage and all Medicare Part D members. The purpose of the publication is to increase awareness about various health-related issues and provide information and resources for prevention and treatment of common ones. Articles include updates on the latest medication treatments, reminders on the importance of taking medications appropriately and lifestyle and diet tips to help individuals with certain medical conditions better manage their health.