Medicare Rx (Medicare Part D) for Medicare recipients impacted those THMP clients concurrently covered by Medicare in a variety of ways. For many recipients, the Medicare Rx coverage is more than sufficient to meet their prescription needs with very minimal premiums and co-payments, and they no longer need to access HIV medications through our program. For some THMP/Medicare recipients dealing with substantially higher premiums and coinsurance payments (not to mention the notorious "doughnut hole" in benefit coverage some clients will encounter where they become responsible for 100% of costs for part of the year), however, their only available Medicare plan options will prove too costly for expensive HIV medication prescriptions; those clients will need financial help from local/community service organizations, plus special continuation of their THMP coverage.
What the THMP is doing:
- All clients who qualify for the full low-income subsidy are required to enroll in a Medicare Part D plan. Remember, if the client has the 100% subsidy they will be able to obtain medications on the plan's list of covered drugs for a co-pay of $5.60 or less per prescription. Once a client is enrolled in a plan they are expected to use the plan to obtain their medications and will be transitioned off of the THMP. If a client experiences problems obtaining medications through their Medicare Rx plan they're welcome to call the THMP at 1-800-255-1090 so that we can provide guidance and assistance.
- All clients who qualify for a partial subsidy or are denied the low-income subsidy will continue to access medications through the THMP. In order to continue to obtain medications from the THMP they will be required to submit a copy of the approval or denial letter for the Extra Help and enroll in a Medicare Part D prescription drug plan. Once the THMP has received a copy of the letter from the client will be transitioned to the new THMP – State Pharmaceutical Assistance Program (SPAP). The SPAP was developed to help with co-pays, coinsurance and gap coverage associated with Medicare Part D prescription drug plans. For more information about the SPAP click here for the THMP SPAP page.
What THMP clients must do:
- All clients who do not automatically qualify for the low-income subsidy (Extra Help) must apply for this assistance. Clients can apply by contacting the Social Security Administration at 1-800-772-1213 or apply online at www.ssa.gov [SSA].
- Please note that it is taking the Social Security administration 3 to 6 weeks to process applications for the Extra Help. Once the application is processed, Social Security will send the client a Notice of Award or Notice of Denial.
- A complete copy of the approval or denial letter for the Extra Help must be submitted to the THMP in order to continue receiving THMP medications. If the client is approved for partial Extra Help or denied the assistance the client will be transitioned to the SPAP as long as the client continues to meet all of the THMP eligibility guidelines.
- If you have questions about this update regarding the THMP and your Medicare eligible clients, please call THMP at 1-800-255-1090 or 512-533-3000 and ask to speak with either Becky Ruiz (ext. 3006).
Other Links of Interest:
Medicare RX Drug Plans in Texas [Texas Department of Insurance]
For Information about the Texas HIV State Pharmaceutical Assistance Program (SPAP), click HERE.
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