Medication Therapy Management

For EmblemHealth VIP Medicare Advantage Prescription Drug Plans:

To be eligible, you must meet the criteria of at least one of the following two groups (1) and/or (2).

1. 1. You take eight or more prescription medications for ongoing conditions covered by Medicare Part D
   2. You have at least three of the following conditions:
      • Chronic congestive heart failure (CHF)
      • Diabetes
      • Hypertension (high blood pressure)
      • Dyslipidemia (high cholesterol)
      • Alzheimer’s Disease
      • Bone disease-arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis)
      • End-stage renal disease (ESRD)
      • Human immunodeficiency virus/Acquired immunodeficiency syndrome (HIV/AIDS)
      • Mental health (including depression, schizophrenia, bipolar disorder, and other chronic/disabling mental health conditions)
      • Respiratory Disease (including asthma, chronic obstructive pulmonary disease (COPD), and other chronic lung disorders)
   3. You must be likely to spend $1,623 or more in 2025 on prescription medications covered by Medicare Part D
2. You have been identified as an at-risk beneficiary (ARB) — that is, you currently have an active coverage limitation under our Drug Management Program (DMP) in one or both of the sections below.
   • Level of opioid use from multiple prescribers and pharmacies:
     • Use of opioids with average daily Morphine Milligram Equivalents (MME) greater than 90 mg for any duration during the most recent 6 months AND either:
       • 3 or more opioid prescribers AND 3 or more opioid dispensing pharmacies; OR
       • 5 or more opioid prescribers (regardless of the number of opioid dispensing pharmacies)
     • Prescribers associated with the same single Tax Identification Numbers (TIN) are counted as a single prescriber.
     • Pharmacies with multiple locations that share real-time data are counted as one pharmacy.
   • History of opioid-related overdose:
     • A medical claim with a primary diagnosis of opioid-related overdose within the most recent 12 months; AND
     • A Part D opioid prescription, not including Medication Assisted Treatment, within the most recent 6 months.

For EmblemHealth Prescription Drug Plans for Group Retirees:

To be eligible, they must meet the criteria of at least one of the following two groups (1) and/or (2).

1. 1. You take eight or more prescription medications for ongoing conditions covered by Medicare Part D
   2. You have at least three of the following conditions:
      • Respiratory Disease (including asthma, chronic obstructive pulmonary disease (COPD), and other chronic lung disorders)
      • Chronic congestive heart failure (CHF)
      • Diabetes
      • Hypertension (high blood pressure)
      • Dyslipidemia (high cholesterol)
      • Mental Health (including depression, schizophrenia, bipolar disorder, and other chronic/disabling mental health conditions) 
      • End-stage renal Disease (ESRD)
      • Bone Disease-Arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis)
      • Alzheimer’s Disease
      • Human immunodeficiency virus/Acquired immunodeficiency syndrome (HIV/AIDS)
   3. You must be likely to spend $1,623 or more in 2025 on prescription medications covered by Medicare Part D
2. You have been identified as an at-risk beneficiary (ARB) — that is, you currently have an active coverage limitation under our Drug Management Program (DMP) in one or both of the sections below.
   • Level of opioid use from multiple prescribers and pharmacies:
     • Use of opioids with average daily Morphine Milligram Equivalents (MME) greater than 90 mg for any duration during the most recent 6 months AND either:
       • 3 or more opioid prescribers AND 3 or more opioid dispensing pharmacies; OR
       • 5 or more opioid prescribers (regardless of the number of opioid dispensing pharmacies)
     • Prescribers associated with the same single Tax Identification Numbers (TIN) are counted as a single prescriber.
     • Pharmacies with multiple locations that share real-time data are counted as one pharmacy.
   • History of opioid-related overdose:
     • A medical claim with a primary diagnosis of opioid-related overdose within the most recent 12 months; AND
     • A Part D opioid prescription, not including Medication Assisted Treatment, within the most recent 6 months.