MTM Program Updates and Part D Safety Measures: Promoting Equity in Pharmacy

August 7, 2025

Since its introduction in 2006, the Medication Therapy Management (MTM) program has been a foundational component of Medicare Part D, developed to ensure patients with complex or chronic conditions receive appropriate medication guidance. However, its impact has been constrained by narrow eligibility criteria and a lack of integration with broader quality initiatives. The Centers for Medicare & Medicaid Services' (CMS) upcoming changes mark a major evolution, one that reflects a growing emphasis on equitable care, patient-centered outcomes, and the central role of pharmacy in improving population health.

Star Ratings and the Role of Pharmacy

Each year, CMS publishes Star Ratings for Medicare Part C and D plans, offering a performance snapshot across quality measures ranging from medication adherence to safety interventions.¹ Although not all display measures directly influence Star Ratings, they play a key role in shaping quality improvement efforts. The Pharmacy Quality Alliance (PQA) continues to shape these metrics, maintaining pharmacy-focused measures that highlight pharmacy’s growing influence in care delivery.²

Major MTM Program Changes for 2025

This year, three adjustments have expanded MTM program eligibility.³ These changes are designed to broaden access and ensure that MTM services are targeted more effectively to high-need populations:

1. Expanded Disease Criteria: In addition to the existing nine core chronic disease states, HIV will now be included. The inclusion of HIV acknowledges its chronic nature and the complexity of medication management required, aligning with public health goals to expand outreach and support to historically underserved populations.
2. Inclusive Drug Criteria: Sponsors must now consider all Part D maintenance drugs in eligibility calculations, using standardized sources for reference. This prevents selective targeting based on drug class profitability and ensures a more clinically relevant and equitable approach to MTM outreach.
3. Lower Cost Threshold: The annual cost threshold for MTM eligibility will be lowered from $5,330 to $1,623, reflecting the average cost of eight generic medications. This adjustment broadens the potential MTM-eligible population by including those with lower overall spend but high risk due to chronic conditions or medication burden.

Collectively, these changes are expected to increase MTM program eligibility from approximately 9% to 23% of Medicare members.³

PerformRx’s Response

At PerformRx, we have historically exceeded CMS’s MTM minimums. Nonetheless, we anticipate our MTM population to double under the new criteria. In preparation, we are scaling our technological capabilities and expanding beyond telephonic outreach to include more community-based and pharmacy-connected services. Over the years, MTM has proven to be one of the most effective tools for driving improved clinical and operational outcomes. PerformRx’s model supports both intervention and long-term engagement through personalized support, multi-channel communication, and collaboration with prescribers and care teams. MTM remains one of the most effective tools to:

• Improve medication adherence.
• Identify gaps in care.
• Address social determinants of health (SDOH).
• Reduce medication-related adverse events.

In our dual-eligible populations, approximately 10% of MTM participants have at least one SDOH-related barrier identified and addressed. For example, PerformRx has coordinated access to community transportation, language translation services, and housing support through cross-team collaboration with plan partners and case managers, extending the reach of MTM beyond medication therapy alone.

Safety Measures Going Prime Time

CMS has elevated two important display measures to Star Ratings status in 2025³:

• Concurrent Use of Opioids and Benzodiazepines (COB): Studies have shown that concurrent use can increase overdose risk by up to 10 times. ^5,6
• Polypharmacy Use of Anticholinergics (Poly-ACH): These medications heighten the risk of cognitive decline, falls, and hospitalization in older adults.⁷

Higher rates in both metrics lead to lower scores, urging plans and PBMs to build data-driven strategies for intervention. Plans without access to integrated, near-real-time pharmacy data may struggle to identify at-risk members or intervene in time. Establishing automated clinical rules, engaging prescribers proactively, and ensuring visibility across transitions of care are critical success factors for addressing these high-impact safety measures.

Medication Adherence Gets an Equity Upgrade

CMS is introducing a risk-adjusted approach to adherence measures that accounts for social determinants and sociodemographic status (SDS).³ The new risk-adjusted scores were publicly displayed in 2024 and will be weighted in 2026. This update ensures plans serving disadvantaged populations are evaluated more fairly. As CMS continues to align quality metrics with social risk adjustment, PBMs and plans must be equipped to analyze disparities in adherence and address barriers through targeted support, education, and culturally responsive care models.

Looking Ahead: The Need for Better MTM Measurement

Current metrics focus on transactional reporting, such as completion of a comprehensive medication review (CMR), but do not capture clinical outcomes. To bridge this gap, PQA launched a national initiative to rethink how MTM quality is measured.⁴ Their Quality Innovation and Research Initiative defines new metrics that better reflect patient engagement, health outcomes, and value-based care principles.

Why It Matters

These changes reinforce the pharmacy's central role in quality care and patient safety. From risk-adjusted adherence to expanding eligibility for vulnerable populations, CMS’s policy direction clearly calls for PBMs and health plans to act. With the right infrastructure and clinical model, the pharmacy can drive both measurable outcomes and meaningful impact, especially for members navigating complex health and social challenges. For plan sponsors and consultants evaluating PBM partnerships, understanding how these changes intersect with your population needs, Star Ratings performance, and long-term strategy is critical. The stakes are higher, but so is the opportunity to lead.

Partner with PerformRx to Elevate Quality and Access

As CMS reshapes Medicare quality measures and expands MTM eligibility, having the right PBM partner has never been more important. PerformRx offers integrated, member-focused solutions that help plans meet evolving Star Rating benchmarks, close adherence and safety gaps, and improve access through high-touch pharmacy engagement. Looking for a PBM partner that combines clinical insight, operational flexibility, and proven MTM impact? Contact us at info@performrx.com to learn how PerformRx can help your organization improve outcomes, strengthen compliance, and support the health of your Medicare population. Sign up today to receive strategic insights, industry updates, and thought leadership from PerformRx. Stay informed on how we're improving patient access and delivering pharmacy solutions that drive better outcomes across the health care landscape.

References

1. Centers for Medicare and Medicaid Services, "Medicare 2024 Part C & D Star Ratings Technical Notes," https://www.cms.gov/files/document/2024-star-ratings-technical-notes.pdf
2. Pharmacy Quality Alliance, "PQA Measure Use in CMS’ Part D Quality Programs," https://www.pqaalliance.org/medicare-part-d
3. CMS, "Contract Year 2025 Medicare Advantage and Part D Final Rule (CMS-4205-F)," https://www.cms.gov/newsroom/fact-sheets/contract-year-2025-medicare-advantage-and-part-d-final-rule-cms-4205-f
4. Cost, M. "Aiming for the Next Generation of MTM Quality Measures," PQA, https://www.pqaalliance.org/index.php?option=com_dailyplanetblog&view=entry&category=performance%20measurement&id=257
5. FDA, "Drug Safety Communication," https://www.fda.gov/Drugs/DrugSafety/ucm518473.htm
6. Dasgupta N, et al. "Impact of High-dose Opioid Analgesics on Overdose Mortality," Pain Med. 2016;17(1):85–98. https://pubmed.ncbi.nlm.nih.gov/26333030/
7. Rudolph JL, et al. "Anticholinergic Risk Scale and Adverse Effects in Older Persons," Arch Intern Med. 2008;168(5):508–513. https://pubmed.ncbi.nlm.nih.gov/18332297/