Crosswalk

Attachment A: Proposed Changes to Medication Therapy Management Program Standardized
Format
A. All Documents
A.1. The inclusion of a logo in the header on the first page of the Cover Letter, Medication
Action Plan, or Personal Medication list is optional. At the discretion of the Part D plan
sponsor, the logo space may be blank on any or all of these three forms, or the
sponsor may choose which logo to include, such as the logo of the parent
organization, Part D plan, or MTM provider. In addition, the plan sponsor has the
option of which side of the header to place the MTM provider information and the
sponsor logo. One can be on the left side and one can be on the right side.
A.2. Technological marks (e.g., barcodes) that do not interfere with the required content of
the standardized format may be included in the margins of the Cover Letter,
Medication Action Plan, or Personal Medication List to facilitate the fulfillment
process.
B. Cover Letter
B.1. In the Cover Letter, change the second sentence in the first paragraph:
From: “Medicare’s MTM (Medication Therapy Management) program helps you to
make sure that your medications are working.”
To: “Medicare’s MTM (Medication Therapy Management) program helps you
understand your medications and use them safely.”
B.2. In the Cover Letter, change the first sentence of the second paragraph:
From: “Along with this letter are an action plan (Medication Action Plan) and a
medication list (Personal Medication List).”
To: “This letter includes an action plan (Medication Action Plan) and medication list
(Personal Medication List).”
B.3. In the Cover Letter, change the first bullet below the second paragraph to make
reference to a care team, such as in a long term care (LTC) facility:
From: “Have your action plan and medication list with you when you talk with your
doctors, pharmacists, and other health care providers.”
To: “Have your action plan and medication list with you when you talk with your
doctors, pharmacists, and other healthcare providers in your care team.”

B.4. In the Cover Letter, change the second bullet below the second paragraph as follows:
From: “Ask your doctors, pharmacists, and other healthcare providers to update them
at every visit.”
To: “Ask your doctors, pharmacists, and other healthcare providers to update the
action plan and medication list at every visit.”
B.5. In the Cover Letter, change the last sentence in the last paragraph:
From: “< I/We > look forward to working with you and your doctors to help you stay
healthy through the < insert name of Part D Plan > MTM program.”
To: “< I/We > look forward to working with you, your doctors, and other healthcare
providers to help you stay healthy through the < insert name of Part D Plan > MTM
program.”
C. Medication Action Plan
C.1. In the Medication Action Plan, change the first sentence in the paragraph below the
instruction bullets to make reference to a care team, such as in a LTC facility:
From: “Have this action plan with you when you talk with your doctors, pharmacists,
and other healthcare providers.”
To: “Have this action plan with you when you talk with your doctors, pharmacists, and
other healthcare providers in your care team.”
D. Personal Medication List
D.1. In the Personal Medication List, change the third bullet of the instructions as follows:
From: “Ask your doctors, pharmacists, and other healthcare providers to update this
list at every visit.”
To: “Ask your doctors, pharmacists, and other healthcare providers in your care team
to update this list at every visit.”