700.006 Multi-Month and Special Circumstance Medication Supply and Coverage
| Policy Number | 700.006 |
| Effective Date | May 1, 2019 |
| Revision Date | May 28, 2024 |
| Subject Matter Expert | Manager, Medication Data and Analysis Group |
| Approval Authority | HIV/STD Section Director |
| Signed by | D'Andra Luna |
1.0 Purpose
This policy provides guidance on multi-month and special circumstances medication supply coverage for medications provided to Texas HIV Medication Program (THMP) participants.
2.0 Authority
Title 25, Texas Administrative Code (TAC) Chapter 98, Texas HIV Medication Program.
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 participants (e.g., low-income, uninsured, or underinsured). The Medication Data and Analysis Group (Group) is responsible for managing and overseeing related operations throughout the state.
The Health Resources and Services Administration (HRSA) provides federal funds for THMP to DSHS, 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 participants and pharmacies. THMP can also provide a 30-day supply of medication filled at a pharmacy outside of Texas for temporarily displaced participants or participants who 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 help support adherence to medication treatment for some THMP participants. Treatment adherence is critical to maintaining the health of persons living with HIV and to reducing HIV transmission by reducing participants’ viral load (the amount of virus within the blood).
4.0 Definitions
AIDS Drug Assistance Program (ADAP) – The State of Texas’ HIV Medication Program (THMP), administered by the HIV Care and Medications Unit.
HIV Care and Medications Unit (HCMU) – The Unit within the HIV/STD Section responsible for oversight for groups that provide services to THMP program participants.
Participant – An applicant determined to be eligible for services who has successfully completed the eligibility process and is receiving services, including medications, through 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 PLWH.
Multi-Month Medication Supply – A medication prescribed or dispensed in a quantity exceeding one month, or 30 days.
Recertification – To continue receiving services through THMP, participants submit documentation every 12 months to verify their eligibility to remain enrolled in the program.
Self-Attestation – The process of a participant updating the Group about changes or confirming no change in the previous eligibility declaration and documentation. Participants 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 SPAP and the Texas Insurance Assistance Program (TIAP).
Texas Insurance Assistance Program (TIAP) – Assists THMP enrollees 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.
5.0 Persons Affected
- Medical providers or physicians
- Pharmacists working at THMP participating pharmacies
- THMP participants
- HIV Care and Medications Unit Staff
6.0 Policy
The Department of State Health Services (DSHS) approves dispensing up to a 90-day supply of certain medications on a regular, ongoing basis upon prescription by a treating physician. THMP participants who need to travel outside of Texas for an extended period due to certain emergencies or circumstantial situations may also be eligible to receive early prescription fills or scripts to cover up to a 90-day period.
THMP participants covered under TIAP or SPAP and who have health insurance are not automatically eligible for a 90-day medication supply on a regular, ongoing basis. These participants 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 their insurance or Medicare Part D Plan approves extended fills, the Group works with the participant to cover expenses for the prescription.
Participants 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 participant’s departure. Participants who need to pick up medication outside of Texas may be eligible to receive a 90-day supply of medication; however, DSHS limits prescriptions filled at an out-of-state pharmacy to a 30-day supply at one time (totaling up to three 30-day fills). THMP participants who require medication accommodations due to travel or out-of-state situations complete the appropriate documentation and receive approval from the program.
Prescribing providers, pharmacists, and participants familiarize themselves with the coverage guidelines, responsibilities, and limitations that could impact the fulfillment of multi-month prescription requests.
7.0 Medication Coverage Guidelines
7.1 90-Day Medication Supply
THMP has approved the network of participation pharmacies to dispense certain medications provided by the program to patients in quantities up to a 90-day supply on a regular, ongoing basis. The option of a 90-day supply is not a requirement, and it is up to the prescribing physician to determine whether the network of participating pharmacies should refill a medication for 30 or 90 days.
A list of medications THMP approves for dispensing as a 90-day supply is posted in the Pharmacy and Medical Provider Guidelines.
7.2 Medication Supply for Special Travel or Out-of-State Situations
THMP may approve participants who do not have regular 90-day prescription refills or who have a prescription for a medication that is not approved for a 90-day supply according to the list of medications
for a 90-day supply of medication in special out-of-state situations (see table below). Participants are only eligible to receive medications in quantities greater than a 30-day supply at one time if they pick up the prescription in the state of Texas.
If a participant experiences a situation listed in the table below and needs a medication refill while out-of-state, the participant 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, a prescription filled outside of Texas is always for 30 days at a time, even if the medical provider wrote the participant’s regular prescription for a 90-day supply.
Each of these special out-of-state situations applies to Texas residents who are temporarily in another state; they do not apply to 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 |
|---|---|---|---|
| Temporary travel out of Texas. | May request up to a 90-day supply of prescribed medications at their assigned THMP pharmacy twice per year. | Submit the THMP Temporary Out of State or Extra Medication Request Form and documentation or proof of travel. | If a prescription fills in a quantity greater than a 30-day supply and the participant reports they lost the supply, the replacement and remaining fills are for 30-days only. |
| A participant enrolled as a student at an out-of-state educational institution who the attending state’s ADAP denied but retains residency in Texas. | May request to pick up medications in the state where the student attends classes during the period of education enrollment. | Submit current proof of out-of-state educational enrollment and an ADAP denial letter from the attending state’s ADAP. | THMP allows a 30-day order 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 or seasonal workers and Temporary job assignments |
The participant may request up to a 90-day supply for coverage while working out-of-state. A participant picks up a fill supplying more than 30 days at one time from their assigned THMP pharmacy in Texas. |
Participant submits the Temporary Out of State or Extra Medication Request Form. |
The Group may approve a multi-month supply for this situation up to twice a year, nonconsecutively. If a participant reports they lost a prescription filled in a quantity greater than a 30-day supply, the replacement and remaining fills are for 30-days only. |
| Temporary leave for an extended period to care for family or address other personal matters out of state. |
A participant may request to pick up up to a 90-day supply at one time from their assigned THMP pharmacy prior to leaving Texas. If the participant is unable to pick up their prescription(s) in Texas, they may request to pick up their medications at an out-of-state pharmacy for a total of up to 90 days (three 30-day fills). |
Participant submits a statement explaining their extended leave of more than 60 days in addition to the Temporary Out of State or Extra Medication Request form. |
Participant may pick up the medication at a local pharmacy in the state where they are visiting, but fills are only for 30 days at a time. The Group may approve a multi-month supply, out-of-state fills, or both for this situation up to twice a year, nonconsecutively. If the participant reports they lost a prescription filled in a quantity greater than a 30-day supply, the replacement and remaining fills are for 30-days only. |
| Natural Disaster Displacement Out of State. | The participant may request to pick up medications at an out-of-state pharmacy for a total period of up to 60 days. | Participant submits a statement of intent to return to Texas or apply to ADAP in the state where they decide to remain. | The participant may pick up the medication at a local pharmacy in the state where they are staying, but fills are only for 30 days at a time. |
| TIAP or SPAP participants with insurance who meet a situation listed above in this table. |
The participant may request to pick up medications at an out-of-state pharmacy. Participants 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 participant is able to pick up a prescription outside of Texas. |
Participants who need to fill out a prescription while out-of-state must submit the Temporary Out-of-State or Extra Medication Request Form to the Group. Participants also need to check with their insurer or Medicare Part D Plan and follow their requirements for these out-of-state situations. |
Participants 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 the insurance permits 90-day fills, the participant follows the requirements set by the insurer or Medicare Part D plan. |
| Participants residing in hurricane-prone areas | A participant may request an early 30-day fill of medication between the months of June and November, which the National Oceanic and Atmospheric Administration (NOAA) recognizes as hurricane season. The participant may collect this fill anytime during the stated period, which allows them to pick up two fills on the same day. |
The participant must reside in a Texas county designated as a coastal area by the (NOAA) or in a Texas county with a disaster declaration during Hurricane Harvey. The participant submits the Extra Medication Request form to collect early fill. |
Early fill is only provided for medications that the participant currently receives as a 30-day fill. Participants with prescriptions for 90-day fills are not eligible to get an early fill during hurricane season. This situation allows participants 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 or SPAP participants with insurance are not eligible to receive this early fill. |
8.0 Responsibilities
8.1 Medical Provider
The medical provider reviews a list of medications
approved for a 90-day supply by ADAP and only writes prescriptions for those included on this list; exceptions exist for participants approved to receive extra medication due to situations stated in Section 7.2 of this policy, Medication Supply for Special Situations.
The medical provider reserves the right to prescribe 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 for dispensing a 90-day supply.
The medical provider submits an updated Medical Certification Form (MCF) to the Group whenever a change in a participant’s regular, ongoing therapy occurs, including a change in medication supply quantity. The provider documents the supply quantity on MCF for each medication prescribed.
The medical provider does not need to write a new script or submit an updated MCF if their participant 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
The pharmacist stays up-to-date on medications that are eligible for a 90-day supply through THMP. Only dispenses multi-month prescriptions for medications on the approved list or when a participant submits a Temporary Out of State or Extra Medication Request Form approved by the Group for an active prescription. Group staff note approval in TakeChargeTexas (TCT) and approve the override when reading the previous notes.
8.3 Participant
A participant who needs an early refill (extra medication) or a multi-month supply of medication due to a situation 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 or Extra Medication Request Form and obtain approval by the Group. Participants with 90-day prescriptions may need to submit the Extra Medication Request Form
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 participant must ensure that their prescriptions are active for the entirety of the time requested by an extended fill. It is the participant’s responsibility to recertify their eligibility to maintain access to medications. If the participant remains out of state for more than 90 days, they may need to fully reapply, including providing current proof of Texas residency.
A participant interested in getting a 90-day supply of their prescribed medications on an ongoing basis should speak to their provider. If a participant submits 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. However, they must submit the required documentation noted in Table 7.2.
8.4 HIV Care and Medications Unit Staff
The staff keeps the list of medications approved for a 90-day supply and the MCF up-to-date. They notify providers and pharmacists to check the guidelines when DSHS changes the formulary.
9.0 Limitations
Medications approved for dispensing as a 90-day supply and fulfilling requests for a multi-month medication supply are at the discretion of the Group and subject to availability and funding constraints. Only those medications included on the THMP Medication Formulary and Maximum Quantities in the Pharmacy Guidelines are eligible to be dispensed in quantities exceeding 30 days, unless otherwise approved by the Group, such as situations listed in Section 7.2 of this policy.
10.0 Medication Replacements
Pharmacies only replace a lost fill over 30 days with a 30-day supply. If a participant reports they lost the 90-day fill medication, the participant is only eligible for 30-day medication refills from that date forward. The Group reassesses returning the participant to a 90-day supply on a case-by-case basis in collaboration with the participant’s medical care team.
11.0 Revision History
| Date | Action | Section |
|---|---|---|
| 5/28/2024 | Removal of public comment to previous revision, changes to statutes, and clarifications of roles and responsibilities | All |
| 5/1/2019 | This is a new policy. | All |