ForwardHealth implemented an MTM benefit in conjunction with the WPQC. The MTM benefit consists of intervention-based services and CMR/As.
Intervention-based services are voluntary face-to-face member assessments and interventions performed by a pharmacist. These services are provided to the member to optimize the member's response to medications or to manage treatment-related medication interactions or complications for both compound and noncompound drugs. Intervention-based services require prescriber approval before the service is performed, with the exception of focused adherence, medication device instruction, and in-home medication management.
Note: Only verbal consent from a member is required for intervention-based services; the member's signature is not required. If the member is a child or has physical or cognitive impairments that preclude the member from managing his or her own medications, a caregiver (e.g., caretaker relative, legal guardian, power of attorney, licensed health professional) may provide verbal consent on the member's behalf.
Intervention-based services may be any of the following types:
Cost-effectiveness intervention — A cost-effectiveness intervention may be one or more of the following: formulary interchange, therapeutic interchange, tablet splitting opportunity, conversion to an OTC product, or dose consolidation.
Three-month supply intervention — Dispensing a three-month supply of drugs streamlines the prescription filling process for pharmacy providers and members, encourages the use of generic, maintenance drugs when medically appropriate for a member, and results in savings to ForwardHealth programs. If the pharmacy contacts the prescriber to amend the prescription, pharmacies are eligible to receive the reimbursement for this service. If the prescription is already prescribed for a three-month supply, pharmacies will not be eligible to receive the reimbursement. Providers may refer to the Three Month Supply Drugs data table for a list of drugs that may be dispensed in a three-month supply.
Dose/dosage form/duration change intervention — Provides the opportunity to change the member's dose, dosage form, or duration of therapy based upon manufacturer recommended dose, organ function or age-appropriateness of dose; insufficient or excessive duration or quantity of medication prescribed; sub-optimal dosage form prescribed; drug-drug interaction or drug-food interaction.
Focused-adherence intervention — Consultation with a member regarding a significant lack of adherence in order to enhance the member's understanding of his or her medication regimen. An adherence tool or referral for a CMR/A may be provided if applicable. A focused adherence intervention may address possible drug misadministration, inability to correctly split tablets, presence of adverse drug reactions, misunderstanding of prescribed instructions, sharing of unauthorized medications, presence of an uncontrolled disease state, prescription of an inappropriate dosage form, concern relating to health literacy or another concern as determined by the pharmacist, and follow-up consultations on focused adherence for a member who has already received a focused adherence intervention. As a reminder, blister and pill card packaging will be reimbursed at the repackaging allowance rate.
Providers are encouraged to follow up with members who have received a focused adherence intervention by calling them on the telephone to ensure they understand what was discussed during the service. These telephone calls are not separately reimbursable.
Medication addition intervention — Recommendation of the addition of a medication based on clinical guidelines, indications, adverse drug reaction, contraindication, black box warning or FDA safety alert, additive toxicity, drug-drug interaction, drug-food interaction, drug allergy, or other reason as determined by the pharmacist.
Medication deletion intervention — Recommendation of the deletion of a medication based on clinical guidelines, indications, adverse drug reaction, contraindication, black box warning or FDA safety alert, additive toxicity, drug-drug interaction, drug-food interaction, drug allergy, or other reason as determined by the pharmacist.
Medication device instruction intervention — Intensive pharmacist consultation lasting more than five minutes on any device associated with a medication and subsequent patient or caregiver demonstration of the device's use. This includes instructing a member to use a new medication device, correcting technique, patient or prescriber request for instruction, or another reason as determined by the pharmacist.
In-home medication management — Provided for members who, due to a physical or mental health condition, are not able to pick up their medication and do not have a family or friend who can pick up the medication, and the medication cannot be mailed to the member's residence, requiring pharmacy staff to travel to the member's home to provide the medication. Examples of medication eligible for this type of intervention include pre-filled syringes, medication that must be refrigerated, or medication that must be stabilized. This intervention may also be used to assist members with device management in the home, such as automated medication dispensing devices. In-home medication management can only be reimbursed in conjunction with a focused adherence, medication device instruction intervention-based service, or a CMR/A. Claims submitted for in-home medication management without a focused adherence intervention, medication device instruction intervention, or a CMR/A will be denied.
Three-month supply and in-home medication management are specific interventions only covered by ForwardHealth. Other WPQC participating payers do not include these services at this time.
Reimbursement
Reimbursement for MTM intervention-based services requires the pharmacist to meet all basic requirements of federal and state law for dispensing a drug, plus completing specified activities that result in a positive outcome for members and ForwardHealth. Positive outcomes include increasing patient compliance or preventing potential adverse drug reactions. This fee reimburses pharmacists for additional actions they take beyond the standard dispensing and counseling for a prescription drug.
Coordination of Benefits
Commercial health insurance and Medicare Part D plans also have MTM programs. If a member is eligible for a commercial health insurance or Medicare Part D MTM program, the pharmacy provider is required to submit the claim to the member's commercial health insurance or Medicare Part D program before submitting the claim to ForwardHealth.
Pharmacies are responsible for COB. ForwardHealth is the payer of last resort.