Part D Coverage

Your Peoples Health plan provides you with coverage for prescription drugs. This includes coverage for all drugs covered by Medicare Part D, as well as some other drugs. For more information about drug coverage through your plan, choose your plan from the list below:

» Peoples Health Choices 65 (HMO)
» Peoples Health Choices Plus (HMO)
» Peoples Health Choices Select (HMO)
» Peoples Health Secure Choice (HMO SNP)
» Peoples Health Secure Health (HMO SNP)
» Peoples Health Group Medicare (HMO-POS)

» Medication Therapy Management
» Utilization Management

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Medication Therapy Management

Peoples Health has established a Medication Therapy Management (MTM) program, with no associated fees, designed to ensure optimum therapeutic outcomes for targeted plan members through improved medication use. The program is also designed to reduce the risk of adverse events, including adverse drug interactions, for targeted plan members.

Targeted plan members for the MTM program meet the following eligibility requirements:

• Have three or more of the following chronic diseases: Alzheimer’s disease, chronic heart failure, chronic kidney disease, chronic obstructive pulmonary disease, diabetes or dyslipidemia
• Are taking two or more covered Medicare Part D medications from specific drug classes
• Are likely to incur annual costs for covered Part D medications that exceed the Centers for Medicare & Medicaid Services-defined cost threshold

Members are automatically enrolled in the program but can opt out and re-enroll at any time. Current members of the program must meet eligibility requirements from year to year. Peoples Health may focus on different medications or health conditions for the program each year.

The MTM program has two parts: a targeted medication review and a comprehensive medication review.

Targeted medication reviews are performed quarterly to assess a member’s medication use, monitor whether any unresolved issues need attention and determine if new drug therapy problems have arisen. Targeted reviews focus on drug utilization specific to each disease state for members with Alzheimer’s disease, chronic heart failure, chronic obstructive pulmonary disease, diabetes or dyslipidemia. For members with chronic kidney disease, targeted reviews focus on potentially harmful drug-disease interactions. In addition, targeted reviews assess high-risk medication use in the elderly and identify therapeutic duplications, drug-drug interactions and drug-disease interactions. All members enrolled in the MTM program receive these reviews.

The comprehensive medication review is an optional service offered to eligible members. If a member chooses to participate in this review, a clinical pharmacist contacts the member to discuss all medications he or she takes, including over-the-counter medications, vitamins and herbal supplements, to identify potential medication-related problems and evaluate medication effectiveness. The clinical pharmacist uses the member’s medication information as well as available lab and test results to conduct the review and may discuss review results with the member’s physician. A follow-up letter, medication action plan and personal medication list based on the review are mailed to the member.

Members can also complete a personal medication list on their own by downloading this form. A personal medication list is a helpful tool for keeping track of medications and how to use them the right way.

Personal Medication List
Download PDF (108 KB)

Targeted members may also receive educational materials on applicable chronic conditions as part of the program.

For more information about the MTM program, call Peoples Health toll-free at (800) 631-8443. TTY users should call 711.

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Utilization Management

The Peoples Health Pharmacy department, in conjunction with the contracted pharmacy benefits manager, maintains management reports and systems to assist in preventing over-utilization and under-utilization of prescribed medications, including, but not limited to, the following:

• Compliance monitoring to improve adherence/persistency with appropriate medication regimens;
• Monitoring procedures to discourage over-utilization through multiple prescribers or multiple pharmacies;
• Quantity versus time edits;
• Early refill edits.

The Pharmacy department maintains methods to ensure cost-effective drug utilization management. This may include, but is not limited to, the following:

• Step therapy;
• Prior authorization;
• Tiered cost-sharing;
• Quantity limits.
  

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