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Single Pharmacy Benefit Manager (SPBM) and Pharmacy Pricing and Audit Consultant (PPAC)

Learn more about SBPM and PPAC as we improve transparency, accountability, and efficiency within ODM’s pharmacy benefits program.

Today, each of Ohio Medicaid’s managed care organizations (MCOs) contracts with a separate pharmacy benefit manager (PBM) for its members. In 2019, the Ohio Legislature directed ODM to make a shift in the program and select and contract with a single PBM (SPBM). ODM’s goals for SPBM are to improve management and administration of pharmacy benefits for managed care recipients. Through SPBM, ODM will gain increased financial accountability and ensure alignment with our clinical and policy goals, while also improving transparency. In partnership with ODM and the next generation Managed Care Organizations (MCOs), the SPBM vendor is Gainwell Technologies.

SPBM Summary

The Pharmacy and Pricing Audit Consultant (PPAC) will work in coordination with ODM and Gainwell to improve transparency, accountability, and efficiency within ODM’s pharmacy benefits program. The PPAC will provide expert assistance and consultation, operational assistance, and liaison support to implement and enhance this operating model. Professional agility, a dedication to high‐quality services and best practices, and value‐based solutions to improve health outcomes and control costs are all necessary to ensure success of the initiatives to reimagine the Ohio Medicaid program. In partnership with ODM, the PPAC vendor is Myers and Stauffer.

On October 1, 2022, the SPBM will begin providing pharmacy services across all managed care plans and members. Until the SPBM goes live on October 1, 2022, there is no change to the current process for submitting pharmacy claims or pharmacy prior authorizations.

  • If the member is only enrolled in OhioRISE, you should continue to submit pharmacy claims and prior authorizations to the Fee-for-Service (FFS) Pharmacy Benefits Administrator, Change Healthcare.
  • For members enrolled in a managed care plan, you should continue to submit pharmacy claims and prior authorizations following the guidance provided by the managed care organization (MCO).
  • Pharmacy claims and prior authorizations for members enrolled in Medicaid FFS should continue to be submitted to the FFS Pharmacy Benefits Administrator, Change Healthcare.

Pharmacies must be enrolled with ODM to contract with the SPBM vendor, Gainwell Technologies. Pharmacies can enroll at any time if they are not already enrolled. To enroll, please visit the Ohio Medicaid Resources for Providers webpage.

Get Your OH|ID By October 1 – The First Step Needed To Access The New PNM and SPBM Modules! 

On October 1, Medicaid providers will need a OH|ID, the State of Ohio’s digital identity standard, to access the Provider Network Management (PNM) Module and Gainwell Technologies’ Single Pharmacy Benefit Manager (SPBM) secure provider portal.  

Click here to create an OH|ID through the state’s login system, ohid.ohio.gov. Providers needing technical assistance can contact Ohio Medicaid’s Integrated Help Desk (IHD) at 1-800-686-1516. The IHD is open Mon.-Fri., 8 a.m.- 4:30 p.m. ET.

Ohio Medicaid is upgrading its provider enrollment system

Effective August 1, 2022, ODM will not be accepting new provider enrollment applications or continue any in-progress enrollment applications through the MITS Provider Enrollment System. Due to the July 1 launch of the OhioRISE program, organizational or individual practitioners who will be providing services covered by the OhioRISE program and behavioral health community providers may enroll with Medicaid and add OhioRISE provider specialties between  August 1 and September 30 to begin providing and billing for services. The guidance was updated on August 31. For guidance on this process, please view the Updated Community BH and OhioRISE Provider Enrollment During System Transition available on the Resources for Community Partners and Providers page of the OhioRISE webpage.

Effective October 1 all provider enrollment applications must be submitted using Ohio Medicaid’s new Provider Network Management (PNM) module. After its implementation, the PNM module will be the single point for providers to complete provider enrollment, centralized credentialing, and provider self-service.