1. Plan Care Manager
MTM Members
Total Members
MTM Eligible
MTM Enrollment
Patient Alerts
Today’s Schedule
12:00 pm Appointment with Ms. Rivera
12.30 pm Appointment with Mr. Davis
01.00 pm Appointment with Mr. Pittman
03.00 pm Appointment with Ms. Bryan
Last Name First Name Member ID PBP No. Alert Type CMRPerformed STARMeasure Opp.
Doull Simon ADE15895 PBP01 DUR Yes Yes
Rast Jennifer XAH16845 PBP03 DDI Yes No
Nicholas Don B14879656 PBP08 Non ADH Yes No
Stokes Karen 146879955A PBP15 CMR Review No Yes
Medwatch
• Recall: FreeStyle InsuLinx Blood
Glucose Meters May Show
Incorrect Results
• FDA Requires Lower
Recommendation Doses of
Simvastatin
• Drug Safety Labeling Changes
• Recall: Brand Name Synthroid and
Levoxyl
• Generic for Diovan is available
now
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2. Plan Pharmacist Manager
MTM Members
Total Members
MTM Eligible
MTM Enrollment
Patient Alerts
Today’s Schedule
12:00 pm Appointment with Ms. Rivera
12.30 pm Appointment with Mr. Davis
01.00 pm Appointment with Mr. Pittman
03.00 pm Appointment with Ms. Bryan
Last Name First Name Member ID PBP No. Alert Type CMRPerformed STARMeasure Opp.
Doull Simon ADE15895 PBP01 DUR Yes Yes
Rast Jennifer XAH16845 PBP03 DDI Yes No
Nicholas Don B14879656 PBP08 Non ADH Yes No
Stokes Karen 146879955A PBP15 CMR Review No Yes
Medwatch
• Recall: FreeStyle InsuLinx Blood
Glucose Meters May Show
Incorrect Results
• FDA Requires Lower
Recommendation Doses of
Simvastatin
• Drug Safety Labeling Changes
• Recall: Brand Name Synthroid and
Levoxyl
• Generic for Diovan is available
now
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3. Plan Executive Portal
67%
20%
13%
MTM MEMBERS 2013
Total Members MTM Eligible
MTM Enrollment
Today’s Schedule
12:00 pm Appointment with Ms. Rivera
12.30 pm Appointment with Mr. Davis
01.00 pm Appointment with Mr. Pittman
03.00 pm Appointment with Ms. Bryan
0
10000
20000
30000
2011 2012 2013 2014
MTMMEMBERS
MTM Plan
Performance
PBP01 PBP02 PBP03
0
10000000
20000000
30000000
2011 2012 2013 2014
Plan vs. Plan Financial Performance
PBP01 PBP02 PBP03
Industry at a Glance
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• Highmark, partners announce creation of Disruptive Health
Technology Institute
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4. Home Patients Reports Help Contact US My Account
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Last Name Member ID
First Name Date of Birth
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Patient Search Results
Last Name First Name Date of Birth Member ID Zip code
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Profile
Prescription History
Diagnosis
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CMR
STAR Measures
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Reporting
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Prior Authorization
Profile
• Patient Last Name
• Patient First Name
• Patient Address – Street, Apt/Suite, City, State, Zipcode
• Patient Phone
• Patient Fax
• Patient Date of Birth
• Patient SSN
• Patient Insurance Information- along with associated family member (Insurance Company Name, Contract Number, Patient Subscriber ID,
Member ID, Suffix ID, Medicare No., Group No., Policy holder’s name (Primary Applicant))
• Patient MTM Enrollment Date
• Patient Allergies (Should be able to edit/add drug information).
• Family History and Medical History
• Patient Memo (Any additional note on patient profile)
• Authorized Individuals
• LTC facility information
• Caregiver information
• Notify RxAdvance about incorrect contact info.
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Prescription History
Diagnosis
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CMR
STAR Measures
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Reporting
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Prior Authorization
Prescription History
(Should be in a Table format) Example
• Patient Last Name
• Patient First Name
• Patient Phone Number
• Patient Date of Birth
• Drug Name
• Drug NDC
• Drug Quantity
• Refill Authorizations
• Directions (How to take)
• Days Supply
• Physician (Provider) Information (Physician Last Name, First Name, Phone/Fax Numbers, Address, License
Number- State and DEA)
• Pharmacy Information (Pharmacy Name, Pharmacy NPI, Pharmacist Name, License Number, Phone/Fax
Numbers)
• Date of Service
• Search by drug name (Should be able to see either way- Brand or Generic)
• Search by time period
• Ability to fax and/or print
• Prescription history/record cannot be modified by user. But they should be able to add another prescription
drug/OTC product separately by typing and saving it to patient profile. These additional entries should appear
different than prescription record.
• Alerts- DUR (Drug Utilization Review), DDI (Drug-Drug Interaction, Brand vs. Generic, Step Therapy, Med
Adherence)
• Pharmacist/Nurse/Case Manager should be able to see Brand vs Generic reference, Alternative drug from
formulary for cost saving
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Diagnosis
Alerts
CMR
STAR Measures
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Reporting
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Prior Authorization
Diagnosis
(Should be in a Table Format)-Ability to add/modify all the data.
• Physicals – Physician Information and Date of Examination
• Lab Test Results – Lab Name, Procedure Name and Date of Test Result
• Hospitals Data
• Diagnosis Code (ICD 10)
• Findings
• Interpretations
• Recommendations
• Table Example:
Provider Date Procedure/
Test
Diagnosis
Code
Diagnosis Details Recommendation Notes Edit Details
Dr. Jaffe xxxx Physical xxx xxx Test Suggestion, Life Style
Recommnedation
xxxxx Edit Updated By: 7/1/13 MR. Lint,
R.Ph, RxAdvance
Quest Lab xxxx Thyroid Blood Test xxx xxx xxxxxxxxxxx xxxxx Edit Updated By: 7/5/13 Mr.
Anderson, Patient
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STAR Measures
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Reporting
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Prior Authorization
Profile Alerts
• Drug Allergy
Zyrtec
Zyrtec contains Carmine. This patient’s profile indicates Carmine as an allergen. Zyrtec poses the risk of
causing an ingredient-based allergic reaction in this patient.
• Drug-Drug Interactions
ibuprofen ↔ lithium
Click here for the monograph
If both drugs are administered, monitor plasma lithium levels and observe the patient for signs and
symptoms of lithium toxicity. Adjust the dose of lithium accordingly.
• Drug-Food Interactions
Lipitor+Grapefruit juice
Side effects from Atorvastatin may get worse if you drink grapefruit juice. Do not take Atorvastatin
with grapefruit juice
• Drug-Disease Contradiction
Minocycline 50 mg
Patient was found to have Pregnancy on their problem list. The drug Minocycline 50 mg cap is
contradicted in patients with Pregnancy
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CMR
STAR Measures
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Reporting
Appointments
Prior Authorization
CMR/TMR
(Should be able to fill out and print these forms in CMS defined standard formats)
• Create CMR (Comprehensive Medication Review) CL ( Cover Letter)
• Create MAP (Medication Action Plan)
• Create PML (Patient Medication List)
• Create “Summary”/”Recommendation” letter and send it along with above 3 documents.
• Able to maintain log about successful and/or failed attempts to contact beneficiary
• Fields for Assessment/TMR (Targeted Medication Review-by phone, face to face, or mail) Questions/Discussion Points – Should be able to
type, print and provide/mail it to patient every quarter or whenever applicable. Memo should be personalized/different for
patient/providers
• Able to
• Able to create a follow-up appointment if necessary and notify patient
• Last CMR Conducted Date
• Other Interventions detailed record- with patients and prescribers, also with other care givers-pharmacists, nurses
• Delivery Method
• Must be able to store these documents, and easily accessible by patients, other providers
• Number of drug therapy problems “recommendations” made to prescribers a result of MTM services
• MTM standard format guidelines for CL, MAP and PML
• MTMMTM-CMS ReqMTM-Program-Standardized-Format-English-and-Spanish-Instructions-Samples-v032712.pdf
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CMR
STAR Measures
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Reporting
Appointments
Prior Authorization
STAR Increase Opportunity – To be decided
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Prescription History
Diagnosis
Alerts
CMR
STAR Measures
Financials
Reporting
Appointments
Prior Authorization
Patient Financials
• Patient Deductible Information
• Patient Co-Pay Information (accumulated)
• Total Drug Cost/Plan Cost (Year To Date)
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STAR Measures
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Reporting
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Reporting
Outcomes Measurement
Recommendations made as a result of MTM services
E.g.
• Needs additional therapy
• Unnecessary drug therapy
• Dosage too high
• Dosage too low
• More effective drug available
• Adverse drug reaction
• Medication Non-Compliance/Non-Adherence)
• Others (Utilization-such as recommending better time to take particular drug or avoiding with particular food)
Drug therapy problem resolutions made as a result of MTM recommendations
E.g.
• Initiate Drug
• Change Drug (such as product in different therapeutic class, dose, dosage form, quantity, or interval)
• Discontinue or substitute drug (such as discontinue drug, generic substitution, therapeutic substitution, or formulary substitution)
• Medication compliance/Adherence
• Other
(User should be able to add/edit notes to each of the above suggestions)
Number of drug therapy problems “recommendations” made to prescribers a result of MTM services
Number of Resolutions made as a result of MTM recommendations
Other criteria specified by CMS
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STAR Measures
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Reporting
Appointments
Prior Authorization
Appointment and Scheduling
• Ability to create an appointment with this patient
• Calendar
• Select date, start-end time, appointment category/appointment notes
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Prescription History
Diagnosis
Prior Authorization
CMR
STAR Measures
Financials
Reporting
Appointments
Prior Authorization
To be decided