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HealthPartners

Coverage criteria policies

Medication Therapy Disease Management Program

These services may not be covered by all HealthPartners plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

Administrative Process

Does not require prior authorization.

Coverage

Medication Therapy Management (MTM) is a disease management program provided by a pharmacist. It is focused on helping patients with chronic medical conditions optimize their medication use in order to improve their health.

MTM is available to:

  1. high risk members (as defined below);
  2. those that receive a referral for MTM services from a health care professional; or
  3. those who self-refer

Visits will be covered when provided:

  1. in person (including services provided in the member’s home);
  2. telephonically; or
  3. via videoconferencing; or
  4. any of the above when delivered to a patient representative acting under a valid Power of Attorney
  5. any of the above when delivered to a member of the patient’s care team at the request of HealthPartners

There is no limit for the number of MTM visits covered in a calendar year. However, HealthPartners may ask for clinical justification from care providers when the number of covered visits in a calendar year exceeds 7.

Definitions

High Risk

  1. Patients with diabetes or coronary artery disease stratified as high risk according to current disease management criteria;
  2. Patients that take 7 (seven) or more unique chronic medications; AND
    1. have been hospitalized in the previous 12 months; OR
    2. have not had an office visit in the last 12 months.

If available, codes for a procedure, device or diagnosis are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all inclusive.

Codes

Description

99605

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, new patient

99606

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, established patient

99607

Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; each additional 15 minutes (List separately in addition to code for primary service)

CPT Copyright American Medical Association. All rights reserved.  CPT is a registered trademark of the American Medical Association.

Products

This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.

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Policy activity

  • 09/08/2011 - Date of origin
  • 11/17/2017 - Effective date
Review date
  • 11/2017

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