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Texas HIV Medication Program

Texas HIV Medication Program

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Texas HIV Medication Program

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  1. Texas HIV Medication Program Becky Ruiz, BSW Katherine Wells, MPH

  2. Presentation Outline • HIV Medication Assistance in Texas • Overview of the Texas HIV Medication Program (THMP) • Application Process • Discussion of problem areas on the THMP application

  3. Help with Medications in Texas • Private Insurance • Patient Assistance Programs • Texas High Risk Pool • City and County Assistance Programs • Medicare • Medicaid • Texas HIV Medication Program • AIDS Drug Assistance Program (ADAP) • State Pharmacy Assistance Program (SPAP)

  4. Patient Assistance Programs • Run by the individual drug manufacturers • Provides free and/or reduced cost medications to eligible individuals • These programs cover HIV Medications as well as medications used to treat side effects and other complications • Some of the major HIV manufacturers are planning to start assisting with insurance co-pays • Helpful websites:;

  5. Local Drug Assistance Programs • Ryan White Funding, Parts A, B, C & D • State Services • County Funds • Local Programs: Carelink (San Antonio), MAP Card (Travis County), Gold Card (Harris County)

  6. Medicare • Federal program that provides medical care for the elderly and disabled • Medicare includes 4 different programs • Part A – Hospital Insurance • Part B – Medical Insurance, individuals must select the program and pay a monthly premium ($96.40) • Part C – Medicare Advantage Plan, provides Part A and Part B benefits through a private company, may provide prescription coverage • Part D – Prescription Drug Benefit, individuals must enroll in an approved plan and pay a monthly premium (avg. $25) • Additional information: or 1-800-633-4227

  7. Medicaid • A state program that provides medical assistance to low income individuals • Medicaid can provide: • Medical Care • Prescription Drugs • Health Insurance Premium Payments • Assistance with the Medicare Part B premium – QMB/SLMB • Income limits are higher for children and pregnant women • For more information call 2-1-1 or 1-877-541-7905 or online at

  8. Texas HIV Medication Program • Administered by the HIV/STD Comprehensive Services Branch within the Department of State Health Services (DSHS) • Mandated under Chapter 85 of the Health and Safety Code • Authorized by the Federal Ryan White CARE Act, 42 USC, Section 300

  9. Texas HIV Medication Program • Program established in 1987 • Provides life-sustaining medications used for the treatment of HIV disease and its related complications to low income Texans • Key philosophies –Access to care and Retention in care • Consists of two programs • AIDS Drug Assistance Program (ADAP) • State Pharmacy Assistance Program (SPAP) • 4th Largest ADAP (NY, CA, FL)

  10. Current Enrollment • 11,651 currently enrolled clients • 10,738 enrolled in the ADAP • 913 enrolled in the SPAP • 13,108 clients served in State FY08 • Program is open to new enrollment/No waiting list • Clients served has increased significantly from 5,106 in 1996 to the 13,108 in 2008 • The THMP dispensed over $75 million in medications to eligible clients in SFY2008

  11. THMP Eligibility • Texas resident • HIV-positive • Uninsured or underinsured for prescription drugs • Low income – Adjusted gross income less than 200% of the Federal Poverty Level (2009) • $21,660/year for a single person • $ 7,480/year for each + family member

  12. Application Process • Fill out the THMP application • Application and Instructions can be downloaded from the web: or contact the THMP to have packet sent • Have the Medical Certification Form (MCF) filled out by doctor • Mail the application and supporting documentation to the THMP

  13. Application Process • Applications are typically processed within 2 to 3 business days of receipt • The applicant and/or their designated authorized person will be contacted by THMP staff if further information is needed. • Once the application is processed, the applicant will be notified of the decision by mail. • If denied by the THMP, the denial letter can be used to access other assistance programs • Clients are required to recertify for the program (ADAP: every 3 years, SPAP: every other year)

  14. Expediting Applications • In some instances applications can be expedited. This means the application can be faxed instead of mailed. • Pregnant Women • Children under 18 years of age • Recently Incarcerated • Special Situations – call the program to discuss the situation before faxing • Note: In order for an expedited application to be approved it must be complete and the applicant must meet all eligibility guidelines.

  15. Texas HIV Medication Program AIDS Drug Assistance Program (ADAP)Clients not eligible for Medicare Texas HIV State Pharmacy Assistance Program (SPAP) Clients eligible for Medicare

  16. Texas ADAP • Funded by Ryan White and State General Revenue • Provides ADAP formulary medications to eligible individuals • Medications are distributed through a network of pharmacies

  17. Texas ADAP Formulary • 42 drugs/80 different formulations • All FDA approved ARVs on formulary • Limited scope-includes 10 of the 14 PHS recommend drugs for the treatment & prevention of OIs – no drugs to treat side effects of toxicities • Medical criteria for the majority of drugs • Limits on the number of antiretroviral medications a client can receive (4 per month)

  18. Accessing Medications • Medications are distributed through a network of community pharmacies • Pharmacies may charge a $5.00 dispensing fee per prescription • A pharmacy cannot refuse service if a client is unable to pay • A list of participating ADAP pharmacies can be found at:

  19. Approved on ADAP – What happens now? • The ADAP enrollee receives an approval letter that includes • Name and Address of Assigned Pharmacy • List of approved medications • Client ID number • The assigned pharmacy receives the same letter • ADAP client takes their prescriptions to the assigned pharmacy and lets the pharmacy know they are part of the Texas HIV Medication Program • Pharmacy will verify prescriptions and order medications from the THMP

  20. What happens now? • THMP receives medications order via fax and phone at the office in Austin • THMP order staff verify the client is enrolled in the program, approved for the medications and if the client has active Medicaid • If the order is denied the pharmacy is notified, common reasons for denial include: • Client not approved for the Medication • Client has open Medicaid slots • Client is on HOLD

  21. What happens now? • If the order is approved, the medication orders are batched and sent to the DSHS pharmacy. • The DSHS pharmacy packs the medications ordered from the local pharmacy and ships the medications via UPS • The medications arrive at the pharmacy, the pharmacist labels the medications and dispenses them to the client • The process can take 3 to 5 business days, therefore it is important for clients to reorder medications before they run out of medications

  22. Texas HIV SPAP • State funded program • Developed to assist clients with Medicare following the creation of Medicare Part D in 2006 • Started January 1, 2008 • Provides assistance with Medicare Part D out of pocket costs • The client must be enrolled in a Medicare Part D plan or a Medicare Advantage Plan w/drug coverage to participate in the program

  23. Texas HIV SPAP Benefit • The SPAP will cover the out-of-pocket costs for an enrollee for medications covered on the enrollees’ Part D plan formulary • Out-of-pocket costs include: • Deductible • Co-payments • Medications during the coverage gap • Co-payments/coinsurance after reaching catastrophic coverage

  24. Texas HIV SPAP Benefit • SPAP enrollees can enroll in any Medicare Part D plan offered in Texas • SPAP enrollees will be responsible for paying monthly Prescription Drug Plan Premiums • The SPAP will assist with all medications covered on the individual’s Part D formulary • The beneficiary must maintain enrollment in a Part D plan in order to access services from the THMP

  25. Texas HIV SPAP Benefit • Annual allowable amount per SPAP enrollee for 2009: $10,995 High End Risk Example:

  26. Medicare Part D Plan Enrollment • Medicare open enrollment is from Nov 15 to Dec 31 each year • A one time Special Enrollment Period (SEP) will be available for newly enrolled SPAP clients • Must give official SPAP name (THMP SPAP) and ID# (SS028) to Medicare/prescription drug plan to successfully enroll the client during the SEP • Clients can enroll by: • Calling the plan directly • Calling 1-800-MEDICARE (633-4227) • Online at

  27. Late Enrollment Penalty • Medicare will assess a late enrollment penalty if a person with Medicare • does not join a Medicare Part D plan when first eligible or • does not have creditable coverage (THMP is not creditable coverage) • The penalty is 1% of the national Medicare premium ($30.36 in 2009) for every month without creditable coverage • The penalty is added to the monthly drug premium • The penalty is permanent and recalculated each year

  28. Example • Bob became eligible for Medicare on April 1, 2008 but did not enroll in a Medicare Part D plan • He later decides to enroll in a plan during the open enrollment period. His plan will be effective on January 1, 2009. • Since Bob is without creditable drug coverage from April 2008 through December 2008 he will be assessed a 9% penalty (1% for each of the 9 months he did not enroll) • In addition to the plan premium Bob will pay an extra $2.73 each month (National Average Premium $30.36 x 9%) • If Bob waits 24 months to enroll in a plan he will have to pay an extra $7.28 per month

  29. How to Enroll in the SPAP • SPAP eligibility is determined by THMP staff • Complete the Texas HIV SPAP Enrollment form • Submit a copy of the LIS partial approval or denial letter from SSA (all pages of the letter) • If not currently enrolled in the THMP, a complete THMP application must also be submitted • Applications can be printed from the THMP website:

  30. Accessing Medications • All SPAP enrollees will receive a welcome packet from Ramsell Holding Corp (Ramsell Public Health Rx) in Oakland, CA, which will include an ID Card • Enrollee will take their ID cards (Part D Plan and SPAP) and prescriptions to a participating pharmacy • Pharmacist will process prescriptions through the Medicare Part D Plan first • If medications are approved, remaining out-of-pocket costs will be billed to SPAP as the secondary payer

  31. Low Income Subsidy/Extra Help • Applications are processed by Social Security • apply online at, fill out a paper application or call 1-800-772-1213 • To qualify for LIS the beneficiary must meet income and asset guidelines • All THMP Clients with Medicare are required to apply for this assistance and submit a copy of the Social Security Determination Letter to the THMP

  32. Full Low Income Subsidy (LIS) • 100% assistance w/ premium, drug costs are reduced to $6.00 per prescription • No coverage gap (donut hole) or deductible • To qualify must have resources below $6,120 and income below $13,784 (135% FPL) • Income and resource limits are adjusted annually and are higher for couples and families • All people with Medicare & Medicaid or are a qualified Medicare beneficiary (receive QMB or SLMB) automatically qualify for full LIS - Not eligible for SPAP

  33. Partial Low Income Subsidy • 25% to 100% assistance w/premium • Drug costs are reduced to 15% co-pays • No coverage gap or donut hole • Reduced drug deductible ($0 – $60) • To qualify resources below $10,210 and income below $15,315 (150% FPL) for a single person • Income and resource limits are adjusted annually and are higher for couples and families - Eligible for SPAP

  34. Helpful Websites • Texas HIV Medication Program Website: • • Low Income Subsidy Application • or 1-800-772-1213 • Medicare, including Part D Plan finder and enrollment information • • Ramsell Public Health Rx TX Pharmacy List (searchable by city, zip, or county) •

  35. Problem Areas on the THMP Application • Missing or inadequate verification of income • Unclear or incomplete representation of household situation, family members, and/or marital status • Invalid proof of Texas residency • Insurance/prescription coverage issues • Missing or incomplete Medical Certification Form (MCF)

  36. What You Can Do To Help • The client is encouraged to explain in writing as much as possible to clarify any part of the application pertaining to them, especially: • Household information • Marital status (if separated, give detailed information about how long, where spouse is, etc.) • Employment situation, especially if not employed (written explanation of when/where last employed) • Support documentation, if zero income a completed THMP Supporter Statement is preferable or any other written support document or statement

  37. What You Can Do To Help • Note that additional documentation from YOU (Social Workers, Case Managers, LVN’s, RN’s) will continue to be needed to clarify any unusual or complicated situations a client may be in • Applications must be completed fully, no blank spaces or marks across pages or areas, please answer each question completely • If either you or the client is uncertain about what the THMP requires in a given situation, please call 1-800-255-1090 and request clarification from our eligibility staff

  38. THMP Contact Information Phone: 1-800-255-1090 or 512-533-3000 Website: