INFORMATION FOR PHARMACISTS’ PARTICIPATION IN THE
STATE EMPLOYEE GROUP INSURANCE PROGRAM
MTM DIABETES MANAGEMENT PROGRAM
1.
2.
3.
4.
5.
6.
7.
DESCRIPTION OF PROGRAM
PROGRAM GOALS
BENEFIT DESIGN
BILLING AND COMPENSATION FOR SERVICES
PATIENT ENROLLMENT
PHARMACIST MANAGEMENT OF PATIENT AND POPULATION
DIABETES MTM LIFESTYLE PROGRAM
1. DESCRIPTION OF PROGRAM
The State Employees Group Insurance Program (SEGIP) estimates that 6,000 state
employees currently are diagnosed with diabetes. There are several health factors
contributing to diabetes that when appropriately managed can improve the health
of the members and reduce the cost to the plan. SEGIP has asked our network to
assist their members in managing their diabetes and medication use.
The UPlan MTM network, on behalf of the 150 participating pharmacist members,
has negotiated a contract to provide medication management services to these State
of Minnesota employees. This program will start on 1 May 2013.
This will be a phased program, beginning with the seven-county Metro area, to be
followed by greater Minnesota later in the year. In the first phase, Metro area
employees (not family members) with a recorded diagnosis of diabetes will be
invited to join the program through a letter and materials describing the SEGIP
MTM Diabetes Management Program. As with our UPlan MTM design, the members
are able to choose the network pharmacist they wish to use and will initiate their
participation by contacting the pharmacist.
2. PROGRAM GOALS
For this program we will focus on improving the D5 Goals developed by the Institute
for Clinical Systems Improvement (ICSI), as a way to describe the five treatment
goals of optimal diabetes care. The five goals that make up the D5 are:





Blood pressure, less than 140/90 mmHG
LDL is less than 100mg/dl
A1c is less than 8%
Tobacco free
Aspirin, as appropriate
UPlan MTM Network/State Diabetes Management Program-4-22-13
1
The purpose of this program is that all patients be at D5 goal. To achieve this,
pharmacists will be asked to manage each patient to these goals.
This will be a new challenge for many pharmacists: to not only manage the patient
but also a defined population of all those members who have chosen your practice.
3. BENEFIT DESIGN
This program is designed as an ongoing program with the ultimate goal of enabling
the members to better manage their diabetes. To that end, the program
recommended that a member meet two or three times during first year of
participation (more often if necessary) and twice a year each subsequent year. It is
coupled with a lifestyle program. The member, on completion of a lifestyle
management program with Journeywell, will receive a $250 deposit to their HRA.
The member is requested to bring a lab report from the physician to the first visit.
The MTM pharmacist will assist members who don’t have current lab values by
contacting their physician. These “base-line values” for the relevant lab values in
the D5 will be reported to the network. At each subsequent visit the pharmacist
will report these values to the network. This is the way we will track the
performance. You will be advised as to the method for reporting these lab values.
Please retain the D5 values in your records for each visit, to facilitate these reports
at a later time.
There are no copayments for the member for the MTM visits. Copayments for
diabetes medications and supplies will be waived while a member actively
participates in the program.
4. BILLING AND COMPENSATION FOR SERVICES
Services will be billed using the same CPT codes as with UPlan (99605, 99606,
99607). Claims will be submitted electronically on a CMS1500 to the relevant
carrier as shown on the member card: Preferred One, HealthPartners or Blue
Cross. (Please note that MTM visit information for UPlan members will continue to
be reported to Medica, and UPlan member enrollment forms faxed to Prime
Therapeutics.)
Pharmacist-provided services will be compensated in the same manner and with
the same fee schedule as with the UPlan program.
In addition this program will have a “pay for performance” aspect. Pay for
performance, although common for many practitioners, is new for pharmacists. It
is expected to be a part of many of the new systems to be developed as part of
health-care reform initiatives.
UPlan MTM Network/State Diabetes Management Program-4-22-13
2
The pay for performance amount will be keyed to movement toward D5 goals of all
enrolled members, over 12 months – across all pharmacists. The network will
retain a portion of this payment for administration of the performance system and
then allocate the remaining performance payment to pharmacists or pharmacies
based on individual performance.
5. MEMBER/PATIENT ENROLLMENT
At the first visit, the SEGIP member will complete and bring to the appointment the
“SEGIP Medication Therapy Management (MTM) Program Member Participation
Agreement.” It should be noted that this Agreement has a section about “participant
responsibilities.” After discussing the program and responsibilities with the
member, the pharmacist should sign and fax the completed form to Navitus. Navitus
will enter the copay waiver into the member’s record. Please advise the member
that it may take up to seven business days for the waiver to be effective.
The participation agreement and other documents related to the SEGIP Diabetes
MTM Program will be available on line. They will be linked to our UPlan MTM
provider site: www.umn.edu/ohr/benefits/pharmacy/mtmproviders/SEGIP.
6. PHARMACIST MANAGEMENT OF PATIENT AND POPULATION
The pharmacist will conduct an MTM Comprehensive Medication Review at the first
appointment with the enrolled member. In addition, the following needs to occur:
1. Document lab and other D5 values. Member has been requested to bring
relevant lab values to first appointment. If the member does not have them
the pharmacist will need to contact the physician.
2. Report D5 values to the network. (Mechanism to be provided.)
3. Establish future appointment – two or three in the first year and two
annually thereafter are recommended. (Pharmacists will need to actively
manage these appointments, as they are integral to the success of the
program.)
4. At subsequent meetings the pharmacist will need to review progress toward
goals and report current D5 values to the network.
In managing the population that you are responsible for (all those members who
have chosen your practice) the pharmacist will need to periodically review results
of your entire group for outliers. It will be important to identify those who are
having difficulty in progressing toward goals and work with them to achieve
success. This is important because the program is based on progress for the entire
group of members in a given pharmacy and the entire enrolled members in all
pharmacies.
UPlan MTM Network/State Diabetes Management Program-4-22-13
3
8.
DIABETES MTM LIFESTYLE PROGAM
As a part of the diabetes management program SEGIP has contracted with
Journeywell®, a lifestyle coaching program, to further aid the members in managing
their health. Enrollment and participation in the Diabetes Medication Therapy
Management (MTM) program is required for participation.
The members can earn $250 in their Health Reimbursement Account (HRA) by
actively participating. The pharmacists should encourage their participation in the
lifestyle management program through Journeywell®, as well as ongoing
participation in the MTM program.
The member can sign up with a health coach at 952-967-5128, 866-977-5128 or
TTY 877-222-2794. Or log on to www.journeywell.com/SEGIP to enroll and identify
themself as a SEGIP MTM program participant.
To be eligible to earn the reward, they need to complete a lifestyle management
program with a health coach or complete one of the online programs (10,000 steps,
eStress or eWeight).
UPlan MTM Network/State Diabetes Management Program-4-22-13
4