To be eligible in 2025, you must meet the criteria of at least one of the following two groups (1) and/or (2). 

    1. You take eight or more prescription medications for ongoing conditions covered by Medicare Part D 
    2. You have at least three of the following conditions:
      • Diabetes
      • Chronic congestive heart failure (CHF)
      • Dyslipidemia (high cholesterol)
      • Hypertension (high blood pressure)
      • Alzheimer’s Disease
      • Bone disease-arthritis (including osteoporosis, osteoarthritis, and rheumatoid arthritis)
      • End-stage renal disease (ESRD)
      • Human immunodeficiency virus/Acquired immunodeficiency syndrome (HIV/AIDS)
      • Mental health (including depression, schizophrenia, bipolar disorder, and other chronic/disabling mental health conditions)
      • Respiratory Disease (including asthma, chronic obstructive pulmonary disease (COPD), and other chronic lung disorders)
    3. You must be likely to spend $1,623 or more in 2025 on prescription medications covered by Medicare Part D.
  2. You have been identified as an at-risk beneficiary (ARB) — that is, you currently have an active coverage limitation under our Drug Management Program (DMP) in one or both of the sections below. 
    • Level of opioid use from multiple prescribers and pharmacies:
      • Use of opioids with average daily Morphine Milligram Equivalents (MME) greater than 90 mg for any duration during the most recent 6 months AND either:
        • 3 or more opioid prescribers AND 3 or more opioid dispensing pharmacies; OR
        • 5 or more opioid prescribers (regardless of the number of opioid dispensing pharmacies)
      • Prescribers associated with the same single Tax Identification Numbers (TIN) are counted as a single prescriber.
      • Pharmacies with multiple locations that share real-time data are counted as one pharmacy.
    • History of opioid-related overdose:
      • A medical claim with a primary diagnosis of opioid-related overdose within the most recent 12 months; AND
      • A Part D opioid prescription, not including Medication Assisted Treatment, within the most recent 6 months.