• DSHS HIV/STD Program

    Post Office Box 149347, MC 1873
    Austin, Texas 78714

    Phone: (512) 533-3000

    E-mail the HIV/STD Program

    E-mail data requests to HIV/STD Program - This email can be used to request data and statistics on HIV, TB, and STDs in Texas. It cannot be used to get treatment or infection history for individuals, or to request information on programs and services. Please do not include any personal, identifying health information in your email such as HIV status, Date of Birth, Social Security Number, etc.

    For treatment/testing history, please contact your local Health Department.

    For information on HIV testing and services available to Persons Living with HIV and AIDS, please contact your local HIV services organization.

700.006

Multi-Month and Special Circumstance Medication Supply and Coverage

Policy
Policy Number  700.006
Effective Date  May 1, 2019
Revision Date 
Subject Matter Expert Manager, Texas HIV Medication Program Group
Approval Authority  HIV/STD Prevention and Care Branch Manager
Signed by  Shelley Lucas, M.P.H.

1.0 Purpose

This policy provides guidance on multi-month and special circumstance medication supply coverage for medications provided by the Texas HIV Medication Program (THMP).

 

2.0 Authority

Texas Administrative Code (TAC), 25 TAC §98.103, Medication Coverage.

 

3.0 Background

The Texas Department of State Health Services (DSHS) receives federal and state funding to purchase and distribute life-saving HIV medications to eligible clients (e.g. low-income, uninsured, or underinsured). The THMP is responsible for managing and overseeing all related operations throughout the state.

Federal funds for the THMP are provided to DSHS by the Health Resources and Services Administration (HRSA), which allows the dispensing of a 90-day medication supply on a regular, ongoing basis. Having the option of a 90-day supply can be beneficial to clients and pharmacies. THMP can also provide a 30-day supply of medication that can be filled at a pharmacy outside of Texas for clients who have been temporarily displaced or travel out-of-state due to unforeseen circumstances and meet criteria described in table 7.2 below.

Both the 90-day medication supply and the 30-day out-of-state emergency refills will help support adherence to medication treatment for some THMP clients. Treatment adherence is critical to maintain the health of persons living with HIV and to reduce HIV transmission by reducing clients’ viral load (amount of virus within the blood).

 

4.0 Definitions

AIDS Drug Assistance Program (ADAP) – The State of Texas’ HIV Medication Program (THMP), administered by DSHS HIV/STD Prevention and Care Branch.

Client – An applicant who has been determined to be eligible for services, has successfully completed the eligibility process, and is receiving services, including medications through the THMP.

Medical Care Team – One or more professionals working to provide services and care to people living with HIV (PLWH). This team can include, but is not limited to, clinicians, case managers, and pharmacists.

Medical Provider – A local organization, individual clinician, or group of clinicians who provide treatment and medical care to people living with HIV (PLWH).

Multi-Month Medication Supply – A medication that is prescribed and/or dispensed in a quantity exceeding one month, or 30 days.

Recertification – In order to continue receiving services through THMP, clients must submit documentation every 12 months to verify their eligibility to remain enrolled in the program.

Self-Attestation – Process of a client updating THMP about any changes or confirming no change in previous eligibility declaration and documentation. Clients must complete a self-attestation every six (6) months.

State Pharmacy Assistance Program (SPAP) – Assists THMP enrollees who have Medicare and an active Medicare Part D prescription card with their premiums and copayments for prescription medications.

Texas Department of State Health Services (DSHS) – The agency responsible for administering physical and mental health-related prevention, treatment, and regulatory programs for the State of Texas. DSHS oversees the Texas HIV Medication Program.

Texas HIV Medication Program (THMP) – Provides medications for the treatment of HIV and its related complications for low-income Texans. The THMP is the official AIDS Drug Assistance Program for the State of Texas. It also operates the State Pharmacy Assistance Program (SPAP) and Texas Insurance Assistance Program (TIAP).

Texas Insurance Assistance Program (TIAP) – Assists THMP enrollees who are covered by an eligible private or employer-sponsored health insurance with paying for prescription medication copayments. TIAP can also pay COBRA premiums for qualifying plans.

Texas Resident – An individual who resides within the geographic boundaries of the state of Texas.

Viral Load – A laboratory test that measures the amount of HIV viral copies in a milliliter of blood.

 

5.0 Persons Affected

  • Providers/Physicians
  • Pharmacists working at THMP participating pharmacies
  • THMP clients
  • THMP staff

 

6.0 Policy

It is the policy of the Department of State Health Services (DSHS) to approve dispensing up to a 90-day supply of certain medications on a regular, ongoing basis upon prescription by a treating physician. THMP clients who need to travel outside of Texas for an extended period due to certain emergency or circumstantial situations may also be eligible to receive early prescription fills or scripts to cover up to a 90-day period.

THMP clients who are covered under TIAP or SPAP and have health insurance are not automatically eligible for a 90-day medication supply on a regular, ongoing basis. These clients must contact their insurer or Medicare Part D representative and follow the policy or requirements their insurance provider or Medicare Part D Plan has established for 90-day prescription fills. If extended fills are approved by their insurance or Medicare Part D plan, THMP will work with the client to cover expenses for the prescription.

Clients who have a regular prescription for a 30-day supply and meet criteria for one of the special travel or out-of-state situations may collect a 90-day fill (picking up 90-days’ worth of medication at one time) if the prescription is filled and picked up at a pharmacy in Texas prior to the client’s departure. Clients who need to pick up medication outside of Texas may be eligible to receive a 90-day supply of medication; however, prescriptions filled at an out-of-state pharmacy can only be filled as a 30-day supply at one time (totaling up to three 30-day fills). All THMP clients needing medication accommodations due to travel or out-of-state situations must complete the appropriate documentation and receive approval from the program.

Prescribing providers, pharmacists, and clients should familiarize themselves with the coverage guidelines, responsibilities, and limitations that could impact fulfillment of multi-month prescription requests.

 

7.0 Medication Coverage Guidelines

7.1 90-Day Medication Supply

THMP has approved certain medications provided by the program to be dispensed to patients in quantities up to a 90-day supply on a regular, ongoing basis. The option for a 90-day supply is not a requirement and it is up to the prescribing physician to determine whether a medication should be refilled for 30 or 90 days. 

A list of medications approved to be dispensed as a 90-day supply is posted in the Pharmacy and Medical Provider Guidelines and available on the program’s website at: www.dshs.texas.gov/hivstd/meds/files/formulary.pdf (PDF : 217 kB).

 

7.2 Medication Supply for Special Travel or Out-of-State Situations

THMP clients who have not been prescribed 90-day refills on a regular basis or who have a prescription for a medication that is not approved to be dispensed as a 90-day supply according to the list of medications (PDF : 216 kB) may be approved to receive up to a 90-day supply of medication in special out-of-state situations listed in the table below. Clients are only eligible to receive medications in quantities greater than a 30-day supply at one time if the prescription is picked up in the state of Texas.

If a client experiences any of the situations listed in the table below and needs a medication refill while out-of-state, the client may be eligible to receive a 30-day supply from a pharmacy located outside of Texas for up to three consecutive months (90 days total). Due to proof of residency requirements, any prescription filled outside of Texas will always be for 30 days at a time, even if the client’s regular prescription is written for a 90-day supply.

Each of these special out-of-state situations apply to Texas residents who are temporarily in another state; they do not apply for out-of-state residents visiting Texas. DSHS Program policy 220.001, Eligibility to Receive HIV Services states that an individual does not lose their Texas residency status due to a temporary absence from the state. For example, a migrant or seasonal worker may leave the state during certain periods of the year but maintain a home in Texas and return to that home after the temporary absence. THMP participants can maintain program eligibility if they maintain a Texas residential address during these absences.

 

Table 7.2: Medication Supply Details for Special Out-of-State Situations

Situation

Medication Assistance

Required Documentation

Notes

Table 2
Temporary travel out of Texas.
May request up to a 90-day supply of prescribed medications at their assigned THMP pharmacy twice per year.

Must submit the THMP Temporary Out of State or Extra Medication Request Form.

Documentation and/or proof of travel may be required.

If a prescription filled in a quantity greater than a 30-day supply is lost, the replacement and all remaining fills will be for 30-days only.

A client is enrolled as a student at an out-of-state educational institution and retains residency in Texas, but client is denied by the ADAP in state where the institution is located.
May request to pick up medications in the state where the student attends classes during the period of education enrollment.
Must submit current proof of out of state educational enrollment and an ADAP denial letter from the attending state’s ADAP.
A 30-day order will be allowed at a local pharmacy on an ongoing basis in the state where the recipient attends school, with verification of school enrollment required with every self-attestation and recertification. 

Migrant/ Seasonal Workers

Temporary Job Assignments

The client may request up to a 90-day supply for coverage while working out-of-state.

Any fill supplying more than 30 days at one time must be picked up from client’s assigned THMP pharmacy in Texas. 

Client must submit the Temporary Out of State or Extra Medication Request Form.

Multi-month supply for this situation may be approved up to twice a year, nonconsecutively.

If a prescription filled in a quantity greater than a 30-day supply is lost, the replacement and all remaining fills will be for 30-days only. 

Temporary leave for an extended period to care for family or attend to other personal matters out of state.

May request up to a 90-day supply to be picked up at one time from their assigned THMP pharmacy prior to leaving Texas.

If client is unable to pick up prescription(s) in Texas, client may request to pick up medications at an out-of-state pharmacy for a total of up to 90 days (three 30-day fills). 

Client must submit a statement explaining their extended leave of more than 60 days in addition to the Temporary Out of State or Extra Medication Request form. 

Client will be allowed to pick up medication at a local pharmacy in the state where visiting, but fills will only be for 30 days at a time.

Multi-month supply and/or out-of-state fills for this situation may be approved up to twice a year, nonconsecutively.

If a prescription filled in a quantity greater than a 30-day supply is lost, the replacement and all remaining fills will be for 30-days only. 

Natural Disaster Displacement Out of State.
The client may request to pick up medications at an out-of-state pharmacy for a total period of up to 60 days.Client must submit a statement of intent to return to Texas or apply to ADAP in the state where client decides to remain. Client will be allowed to pick up medication at a local pharmacy in the state where the client is staying, but fills will only be for 30 days at a time. 
TIAP/SPAP clients with insurance who meet any of the situations listed above in this table.

The client may request to pick-up medications at an out-of-state pharmacy.

Clients must contact their insurer or Medicare Part D Plan to determine eligibility and requirements regarding the maximum quantity of medication that can be supplied at one time (if picking up medication in Texas prior to extended travel) as well as the maximum duration that a client is able to pick up a prescription outside of Texas. 

Clients who need to fill a prescription while out-of-state must submit the Temporary Out of State or Extra Medication Request Form to THMP.

Clients also need to check with their insurer or Medicare Part D Plan and follow any of their requirements for these out-of-state situations. 

Clients leaving Texas for an extended period (up to 90 consecutive days) must check with their insurer or Medicare Part D plan to determine whether their plan provides 90-day prescription fills and if so, which medications are eligible for extended fills. If 90-day fills are permitted, client should follow the requirements set by the insurer or Medicare Part D plan.
Clients residing in hurricane-prone areas
A client may request an early 30-day fill of medication between the months of June and November, which are recognized as Hurricane Season. This fill can be collected anytime during the stated period and allows for two fills to be picked up on the same day. 

The client must reside in a county designated as a coastal area by the National Oceanic and Atmospheric Administration (NOAA) or in a county with a disaster declaration during Hurricane Harvey

Client must submit the Extra Medication Request form in order to collect early fill.

Early fill will only be provided for medications that the client currently receives as a 30-day fill. Clients with prescriptions for 90-day fills are not eligible to get an early fill during hurricane season. 

This situation allows clients in hurricane-prone areas to get one early refill during hurricane season—it does not change the total number of prescription fills available.

This medication assistance situation only applies to ADAP participants; TIAP/SPAP clients with insurance are not eligible to receive this early fill. 

 

8.0 Responsibilities

8.1 Medical Provider

Reviews list of medications (PDF : 219 kB) approved for a 90-day supply by ADAP and only write prescriptions for those included on this list; exceptions exist for client’s approved to receive extra medication due to situations stated in section 7.2 of this policy, Medication Supply for Special Situations.

Providers should reserve prescribing a 90-day medication supply for people on stable medication regimens; medications that are new or have changed in dose for a patient are not eligible to be dispensed as 90-day supply.

Submits updated Medical Certification Form (MCF) to THMP whenever a change in client’s regular, ongoing therapy occurs, including a change in medication supply quantity. Supply quantity must be documented on MCF for each medication prescribed.

Providers do not need to write a new script or submit an updated MCF if their client has a regular prescription for a 30-day supply but needs additional medication on a temporary basis due to one of the situations listed in Table 7.2.

 

8.2 Pharmacist 

Stays up-to-date on medications (PDF : 219 kB) that are eligible for a 90-day supply through the THMP. Only dispenses multi-month prescriptions for medications on the approved list or when a Temporary Out of State or Extra Medication Request Form approved by THMP is submitted for an active prescription.

 

8.3 Client

A Client who needs an early refill (extra medication) or a multi-month supply of medication due to any situations described in section 7.2 of this policy, Medication Supply for Special Travel or Out-of-State Situations, must complete the Temporary Out of State (PDF : 149 kB) or Extra Medication Request Form (PDF : 173 kB) and obtain approval by the THMP. Clients with 90-day prescriptions may need to submit the Extra Medication Request Form (PDF : 173 kB)  if they are traveling or temporarily out of the state and the timing of their prescription refills does not coincide with the amount of medication needed to cover the duration of their travel.

The client must ensure that their prescriptions are active for the entirety of time requested by an extended fill. It is the client’s responsibility to recertify their eligibility to maintain access to medications. If the client remains out of state longer than 90 days, he or she may be required to fully reapply, including current proof of Texas Residency.

A client should talk to their provider if they are interested in getting a 90-day supply of their prescribed medications on an ongoing basis. However, if a client is submitting a request for early or additional medication fills because of a temporary travel situation, they do not need to get authorization or a new script from their provider, but they must submit the required documentation noted in Table 7.2.

 

8.4 THMP

Keeps the list of medications approved for a 90-day supply and the MCF up to date. Notifies providers and pharmacists to check the guidelines when changes to the list have been made.

 

9.0 Limitations

Medications approved to be dispensed as a 90-day supply and fulfilling requests for a multi-month medication supply are at the discretion of the THMP and subject to availability and funding constraints. Only those medications included on the THMP Medication Formulary and Maximum Quantities (PDF : 219 kB) in the Pharmacy Guidelines are eligible to be dispensed in quantities exceeding 30 days, unless otherwise approved by the THMP, such as situations listed in section 7.2 of this policy.

 

10.0 Medication Replacements

A lost fill over 30 days will only be replaced as a 30-day supply. If a 90-day fill is lost, the client will only be eligible for 30-day medication refills from that date forward. Returning to a 90-day supply will be reassessed by THMP on a case-by-case basis in collaboration with the client’s medical care team.

 

11.0 Revision History

Date Action Section
Revision History
5/1/2019 This is a new policy. All

 


 

Last updated July 11, 2019