• DSHS HIV/STD Program

    Post Office Box 149347, MC 1873
    Austin, Texas 78714

    Phone: 737-255-4300

    Email the HIV/STD Program

    Email 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.

Texas HIV Medication Program – Medical Certification Form Quick Facts


THMP receives and processes numerous MCFs for our clients every day.

Below is a quick reference for some of the most frequently asked questions about MCFs. (Medical Certification Form Quick Facts print version - PDF : 539 kB)


How can my client receive a 90-day prescription?

  • If the client is new to any medications on the antiretroviral therapy regimen or this box is unchecked, the client is ineligible.
  • Please evaluate each client’s situation before prescribing 90-day prescription fills (treatment experienced with existing medication, living situation, ability to keep track of medications, etc.).
  • Certain medications are eligible for 90-day prescription fills – Please refer to the THMP Medication Formulary and Maximum Quantities Table (PDF : 288 kB) for available mediations/dosages.
  • Clients covered under Texas Insurance Assistance Program (TIAP) or State Pharmacy Assistance Program (SPAP) with health insurance must contact their insurer or Medicare Part D representative and follow the policy or requirements their insurance provider or Medicare Part D Plan for 90-day prescription fills.
  • Please see the THMP 90-day prescription policy.


What other important information do I need to know about MCFs?

  • MCFs must be signed by a physician or mid-level provider (physician’s assistant, nurse practitioner).
  • When a client’s medication regimen changes a new MCF must be submitted to THMP 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 (PDF : 288 kB)).
  • 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. Please refer to the THMP Medication Formulary and Maximum Quantities Table (PDF : 288 kB) for available mediations/dosages.
  • MCFs with a new request for Selzentry must include a copy of 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.


What if my client is prescribed Hepatitis C medications or Trogarzo?


How do I submit an MCF to THMP?

  • For new applicants, the MCF should be included with the THMP application.
  • Always fax a MCF for medication changes to THMP at (512) 989-4003.
  • NEVER email a MCF or any information that has identifying/personal health information.


What do I need to check before submitting an MCF?

  • All client information must be completely filled out.
  • Lab values are requested but are not required if 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 physician/provider’s signature.


 


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Last updated October 13, 2020