Medicare Part D (Medicare Rx) for Medicare recipients impacted THMP clients covered by both Medicare and the Texas HIV Medication Program (THMP) in a variety of ways. Two noticeable impacts have been:

• Some recipients of Medicare Rx coverage still have substantially higher premiums and coinsurance payments for their medications.
• Additionally, during parts of the year, these recipients do not have benefits coverage and will be fully responsible for 100 percent of costs incurred during that time (also known as “the donut hole”).

Clients who meet the criteria will need financial help from local or community service organizations and, in addition, will receive a special continuation of their THMP coverage.
 

What will this do to my THMP coverage?

Clients who qualify for the full low-income subsidy must enroll in a Medicare Part D plan.

• If the client has the Tier 1 (100 percent) subsidy, they can obtain medications on the plan's list of covered drugs for a co-pay of $5.60 or less per prescription.
• Once a client enrolls in a plan, they must use the plan to obtain their medications.
• After enrolling in a Medicare Rx plan, the client will transition off THMP.

If a client has problems obtaining medications through their Medicare Rx plan, they can call THMP at 800-255-1090 for guidance.
 

I don’t qualify for Extra Help. What can I do to keep receiving medications from THMP?

All clients who do not automatically qualify for the low-income subsidy (Extra Help) must apply for this assistance and enroll in a Medicare Part D program before contacting THMP.

• Clients can apply by contacting the Social Security Administration at 1-800-772-1213 or online at ssa.gov.
  • Please note that the Social Security Administration can take three to six weeks to process applications for the Extra Help subsidy.
• Once the Social Security Administration processes the application, they will send the client either a Notice of Award or a Notice of Denial letter.
• Clients must submit a complete copy of the approval or denial letter to THMP to continue receiving THMP medications.
• If the client receives partial approval for the Extra Help subsidy or does not receive the subsidy, and the client still meets THMP eligibility guidelines, they will transition to THMP’s State Pharmaceutical Assistance Program (SPAP).
• THMP developed SPAP to help with co-pays, coinsurance, and gap coverage associated with Medicare Part D prescription drug plans.

If you have questions regarding THMP and Medicare-eligible clients, please call THMP at 800-255-1090.
 

Resources

1. medicare.gov
2. ssa.gov
3. Medicare RX Drug Plans in Texas

Learn more about the Texas HIV State Pharmaceutical Assistance Program (SPAP).