University of Minnesota
Office of Human Resources

Medication Therapy Management (MTM) Provider Information

The University of Minnesota Health Plan (UPlan) invites pharmacists to join the UPlan MTM Provider Network, to provide MTM services to eligible University employees and their dependents across Minnesota, and to employees participating in the State of Minnesota SEGIP(State Employee Group Insurance Plan) Diabetes MTM Program.

MTM providers are needed throughout the State of Minnesota

Pharmacist Eligibility

Pharmacists are eligible to become MTM providers in the UPlan network if they graduated during or after 1996, or have completed an approved continuing education course.

Application to Join the UPlan MTM Provider Network

        MTM Provider Application and Release Form (pdf)

Information for Network Provider

The Complete UPlan MTM Benefit Program Design Statement (pdf)
Frequently Asked Questions (pdf) 
UPlan MTM Policies and Procedures (Administrative Program) (pdf) 
General Instructions for Submitting MTM Claims (pdf) 
Key Contact Information for UPlan MTM Providers (pdf) 
MTM Fee Structure (Excel) 
UPlan MTM/SEGIP Program Comparison 

University of Minnesota UPlan MTM Program 

UPlan Member Eligibility

UPlan members are eligible to participate in MTM services if they are currently taking four or more UPlan-covered prescription and over-the-counter medications for chronic conditions or are referred by their physician. A referral request form is available below.

         Referral Request for Medication Therapy Management Services (pdf)

UPlan Wellness Program

UPlan members who participate in the MTM program have the opportunity to earn points in the UPlan's Wellness Program.  These points can be used toward a reduction on annual medical premiums. 

Note: There is no longer an enrollment form for UPlan MTM. To accumulate points toward a reduction in health care premiers, the employee must enroll in the UPlan's Wellness Program at

UPlan Formulary

Prime Therapeutics LLC is the Pharmacy Benefit Manager for UPlan prescription claims. Pharmacists enrolled as providers in the UPlan MTM Network should consult the UPlan drug formulary when making recommendations for changes in a patient's medication therapy. The current University of Minnesota UPlan Formulary  lists the medications that are covered by the program.  

UPlan Prior Authorization (PA), Step Therapy (ST) and Affordable Care Act (ACA) information 

Prior Authorization Program(pdf) 
Step Therapy Program(pdf) 
Prior Authorization and Step Therapy Criteria(pdf) 
Prior Authorization Forms  (choose "Get Forms") 
ACA Preventive Medications(pdf) 
ACA Contraceptive Medications(pdf)  

State Employee Group Insurance Plan (SEGIP) MTM Diabetes Program

As of June 1, 2013, the UPlan MTM Network is providing MTM services for State of Minnesota employees with diabetes. Eligible employees receive invitations  to enroll. However, all SEGIP employees with a diagnosis of diabetes are eligible for the program and credentialed network pharmacists may enroll any employees who fits the criteria for participation. Currently, spouses and covered dependents are not eligible for this program. For more information on program eligibility see SEGIP FAQs.  

Links to State Web Site for SEGIP MTM Diabetes Program      

SEGIP MTM State Website
SEGIP Program Letter to Pharmacists
SEGIP Program Description for Pharmacists

SEGIP MTM Diabetes Management Program Forms and Documents

SEGIP Member Participation Agreement
SEGIP Medication Record Form
SEGIP Health Screening Form
SEGIP Key Contact Information

SEGIP D5 Data Submission

SEGIP D5 Letter
Data File Instructions-EMR 
Date File Instructions-Excel

SEGIP Member Information

SEGIP Invitation to Enroll

SEGIP Member Disenrollment Form

SEGIP Disenrollment Letter to Pharmacists
SEGIP Member Disenrollment Form

Program Contacts

Julie Balthazor
MTM Benefit Program Coordinator

Office location:
B288 Mayo Memorial Building
420 Delaware Street S.E.
Minneapolis, MN 55455

Mailing address:
7-159 WDH 
308 Harvard Street S.E.
Minneapolis, MN 55455