Provider Resources & Forms

Gold Kidney Provider Reference Guide

Part C Related Documents and Forms

Medicare Advantage Plan Information

Waiver Of Liability

Provider Information Change Form

Annual Wellness Visit Form

Advance Directives - (Arizona)

Prior Authorization Request Process

Prior Authorization Form (Part C)

Risk Management Form (Florida)

Pharmacy Part D Related Documents and Forms

Birdi Mail Order Form

Prescription Coverage Determination Request Form

Prescription Coverage Determination Request - Submit Online

MedImpact Claim Form Part D

Prior Authorization Form (Pharmacy)

Medication Therapy Management Program (MTM)

2024 Medication Therapy Management (MTM)

If you’re in a Medicare drug plan and you have complex health needs, you may be able to participate in a MTM program. MTM is a service offered by Gold Kidney Health Plan at no additional cost to you! The MTM program is required by the Centers for Medicare and Medicaid Services (CMS) and is not considered a benefit. This program helps you and your doctor make sure that your medications are working. It also helps us identify and reduce possible medication problems.

To take part in this program, you must meet certain criteria set forth in part by CMS. These criteria are used to identify people who have multiple chronic diseases and are at risk for medication-related problems. If you meet these criteria, we will send you a letter inviting you to participate in the program and information about the program, including how to access the program. Your enrollment in MTM is voluntary and does not affect Medicare coverage for drugs covered under Medicare.

To qualify for Gold Kidney Health Plan’s MTM program, you must meet one of the two following criteria:

  • Be an At-Risk Beneficiary or
  • Meet ALL of the following criteria:
    • Have at least 3 of the following conditions or diseases: Chronic Heart Failure, diabetes, dyslipidemia, hypertension, asthma, or Chronic Obstructive Pulmonary Disease, AND
    • Take at least 8 covered Part D medications, AND
    • Are likely to have medication costs of covered Part D medications greater than $5,330 per year

To help reduce the risk of possible medication problems, the MTM program offers two types of clinical review of your medications:

  • Targeted medication review: at least quarterly, we will review all your prescription medications and contact you, your caregiver, your pharmacist, and/or your doctor if we detect a potential problem.
  • Comprehensive medication review:at least once per year, we offer a free discussion and review of all of your medications by a pharmacist or other health professional to help you use your medications safely.  This review, or CMR, is provided to you confidentially via telephone by call centers operated by Aspen RxHealth.  The CMR may also be provided in person or via telehealth at your provider’s office, or long-term care facility. These services are provided on behalf of Gold Kidney Health Plan. This review requires about 30 minutes of your time.   Following the review, you will get a written summary of this call, which you can take with you when you talk with your doctors.


This summary includes:

  • Recommended To-Do List (TDL): The list has steps you should take to help you get the best results from your medications.
  • Personal Medication List (PML): The medication list will help you keep track of your medications and how to use them the right way.

To obtain a blank copy of the Personal Medication List (PML) that can help you and your health care providers keep track of the medications you are taking, click here Blank PML English or Blank PML Spanish.

If you take many medications for more than one chronic health condition contact Gold Kidney Health Plan to see if you’re eligible for MTM, or for more information, please contact customer service at 844-294-6535

Provider Dispute Form

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