Dear Network Pharmacist:
We realize there is a need, in certain circumstances, to remove a patient from participation in the SEGIP
Diabetes MTM program (Example: Enrolled but did not schedule MTM visit). Please find attached a form
and process for disenrolling a SEGIP member from the program.
We anticipate that situations requiring disenrollment will be few and far between. Because SEGIP and
the network want to give enrolled members every opportunity to maintain their participation in the
program, we ask that you initiate the disenrollment process only:


After several attempts has been made to contact the member.
If the member has expressed a desire to no longer participate.
This process requires you to make a final contact with the patient and document the results of that
contact. When that final contact has taken place and you have determined the patient is not meeting
his/her responsibilities as defined in the Member Participation Agreement, use the “Request for Notice
of Disenrollment” form to initiate the process.
Step 1. Complete the first section and fax it to Navitus, per instructions on the form. This will
generate an official letter to the member advising them of the 30 day notice. Keep a copy of the form.
Step 2. We anticipate that once the patient receives the 30 day notification of disenrollment he/she may
be motivated to schedule an appointment. The second section should be completed at the end of the
30 days if no appointment has occurred. Fax the entire form (both pages), with the Final
Disenrollment section completed to Navitus.
This form will also be made available on our web page www.umn.edu/ohr/benefits/pharmacy/mtmproviders
Please contact me (schne024@umn.edu), or Julie Balthazor (balt0012@umn.edu), if you have any
questions about this process.
Thanks for helping us with this.
Gary Schneider
Director, Medication Management Network
College of Pharmacy
University of Minnesota