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St. Louis County offices will be closed Monday, September 7, in observance of the Labor Day holiday.
Missing MTM Discount
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Missing MTM Discount
Answer these questions for each medication (one at a time).
To qualify for the MTM copay discount, your medication must treat one of the following:
Heart disease
High blood pressure
High cholesterol
Depression
Diabetes
Asthma
COPD
Does your medication qualify?
Yes
No
If you have additional questions, contact Beth Menor, Benefits Advisor, at
menorb@stlouiscountymn.gov
or 218-725-5056.
Return to Benefits page
Health plan member
First Name
Last Name
Plan ID number (numeric portion only)
Last consult with MTM pharmacist
Month
-
Day
-
Year
MTM Pharmacist
First Name
Last Name
Pharmacy where copay discount was missing
City in which pharmacy is located
Date copay was missing
Month
-
Day
-
Year
Was the medication picked up or rejected?
Picked Up
Rejected
Others
How many days did your prescription cover?
Copay you were expecting
Is this your first time filling this medication?
Yes
No
Are you out of this medication?
Yes
No
When will you run out?
Month
-
Day
-
Year
Have you filled this prescription under the MTM program in the past?
Yes
No
What year(s)?
Copay amount you paid prior
Number of days filled prior
Is your medication a generic or a brand name?
Generic
Brand Name
Unknown
Email we may contact you at
Phone number we may contact you at
Area Code
Phone Number
Captcha