Texas HIV Medication Program

Texas HIV Medication Program

Becky Ruiz, BSW

Katherine Wells, MPH

TA Conference CallMarch 6, 2009

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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


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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)


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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: www.needymeds.com; www.RxAssist.org


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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)


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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: www.medicare.gov or 1-800-633-4227


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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 www.YourTexasBenefits.com


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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


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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)


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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


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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


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Application Process

Fill out the THMP application Application and Instructions can be downloaded

from the web: www.dshs.state.tx.us/hivstd/meds 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


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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)


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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.


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Texas HIV State Pharmacy

Assistance Program (SPAP)

Clients eligible for Medicare

AIDS Drug Assistance Program

(ADAP)Clients not eligible

for Medicare



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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


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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)


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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: www.dshs.state.tx.us/hivstd/meds/pdf/pharlist.pdf


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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


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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


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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


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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


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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


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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


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Retail Cost Part D Coverage PeriodOut-of-Pocket

Month 1 $10,000 $4,522Deductible, Initial Coverage, Coverage Gap, Catastrophic

Month 2 $10,000 $500 Catastrophic Coverage

Month 3 -12 $100,000 $5,000 Catastrophic Coverage (10 months)

Total $120,000 $10,022


Annual allowable amount per SPAP enrollee for 2009: $10,995

High End Risk Example:


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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 www.Medicare.gov


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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


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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


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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:

www.dshs.state.tx.us/hivstd/meds


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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


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Low Income Subsidy/Extra Help

Applications are processed by Social Security apply online at www.ssa.gov, 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


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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


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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


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Helpful Websites Texas HIV Medication Program Website:

www.dshs.state.tx.us/hivstd/meds Low Income Subsidy Application

www.ssa.gov or 1-800-772-1213 Medicare, including Part D Plan finder and

enrollment information www.medicare.gov

Ramsell Public Health Rx TX Pharmacy List (searchable by city, zip, or county) www.publichealthrx.com/tx_spap.html


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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)


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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


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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


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THMP Contact Information

Phone: 1-800-255-1090 or 512-533-3000

Website: www.dshs.state.tx.us/hivstd/meds

Staff Extension Area of Expertise

Becky 3006 Case Management, Eligibility, Medicare

Christine 3003 Recertification Lead

Juliet 3004 SPAP Lead

Jack 3012 Incarcerated Populations

Katherine 3008 SPAP

Kelley 3011 Order Processing Lead

Krystal 3009 Eligibility

Stacy 3007 Eligibility

Texas HIV Medication Program

Documents

Transcript of Texas HIV Medication Program