THMP – Medical Certification Form Quick Facts

A 90-day supply is available for a limited number of medications and as an exception to the normal dosing schedule, for example, as a vacation supply.

• MCFs must be signed by a physician, physician’s assistant, or nurse practitioner.
• When a client’s medication regimen changes, a new MCF must be submitted to the Texas HIV Medication Program with the complete regimen selected.
• MCFs have a four (4) anti-retroviral (ARV) drug limit – some drug “boosters” are allowable as a fifth drug (see Formulary).
• THMP Pharmacy Coordinator must approve medication requests that exceed five (5) drugs or unusual combinations. A letter from the provider must be included justifying the request.
• High dosages require a signed letter of justification from the provider. Refer to the THMP Medication Formulary and Maximum Quantities Table for available medications/dosages.
• MCFs with a new request for Selzentry must include a copy of the Trofile/CCR5 test.
• THMP will provide the generic equivalent of prescribed medication when available – refills may be different generic equivalents depending on inventory at the time of each refill.
• Address and pharmacy changes may not be requested on MCF.

The Hepatitis C medication pilot is currently suspended. View the Trogarzo MCF.

• For new applicants, the MCF should be included with the THMP application. In the Take Charge Texas (TCT) portal, the MCF can be scanned in as a proof of positivity document.
• Always fax an MCF for medication changes to THMP at 512-989-4003.
• NEVER email an MCF or any information that has identifying/personal health information. 

• All client information must be completely filled out.
• Lab values are requested but are not required if the client is new and does not have labs completed.
• Each medication requested is checked on MCF.
• All physician/provider information must be filled out.
• MCF includes the physician/provider’s signature.