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))
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) 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)).
- 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) 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 512-533-3178.
- 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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