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Ohio Medicaid Single Pharmacy Benefit Manager (SPBM)

Ohio Medicaid Single Pharmacy Benefit Manager (SPBM)

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 October 2022, the SPBM will begin providing pharmacy services across all managed care plans and members. Until the SPBM goes live in October 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.

SPBM Summary

Ohio Medicaid Next Generation Pharmacy Program

On Friday, April 15th, the Ohio Department of Medicaid along with its partners Gainwell and Myers & Stauffer held the second in a series of webinars with Pharmacy Stakeholders detailing the Specialty Pharmacy program. The goal of the SPBM program is to ensure transparency, accountability, and overall program integrity to better serve the Ohio Medicaid members and facilitate improved administrative processes for providers. The presentation from this meeting can be found here.

What is the role of the SPBM?

For Medicaid managed care members, the SPBM will provide more choice in selecting their pharmacy due to fewer out-of-network restrictions. In addition, members will no longer need to consider pharmacy benefits as a decision-making factor when selecting a managed care plan. The SPBM can also incentivize member-valued services and benefits like home delivery, 90-day refills, and adherence programs.  

Through SPBM, pharmacists and prescribers will see benefits from streamlining and consolidation of processes currently provided by multiple, individually contracted PBMs. For example, pharmacists can streamline inventory based on the Unified Preferred Drug List (UPDL) and a single set of guidelines. The SPBM will also include implementation of a single set of clinical and prior authorization policies and claims process, and provide a standard point of contact, reducing the administrative burden on providers. These changes simplify and improve information exchange between pharmacies, providers, and MCOs to drive improved member care management opportunities. 

Another important objective is reflected in the overall approach that ODM is taking to unbundle several components from the current managed care plan responsibilities in order to provide transparency and focused specialization in areas of critical need identified by stakeholders and the General Assembly. This is not returning to fee for service. Rather this is an affirmative strategy to move Ohio to the “next generation” of managed care expertise. With the SPBM structured as a prepaid ambulatory health plan, the state will have the managed care tools and flexibilities for advancing policy and cost effectiveness of services. In addition to the pharmacy benefit being important in and of itself, it is also vitally important to supporting ODM’s overall value-based and integrated care strategies.

What is the Pharmacy Pricing and Audit Consultant (PPAC)?

The 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.

The Ohio Medicaid PPAC will assist and support ODM in the performance of two critical pharmacy services functions:

  • Pharmacy reimbursement and benefit design
  • Pharmacy program oversight and auditing

The PPAC will be central to achieving transparency through its work in determining reimbursement methodology, conducting Cost of Dispensing (COD) and Actual Acquisition Cost (AAC) surveys, maintaining accurate and up to date AAC rates, and conducting oversight of the functions of both the SPBM and the ODM’s fee-for-service pharmacy benefits administrator (FFS PBA). The success of this pharmacy benefit administration model, and the PPAC specifically, will be demonstrated by fair, accurate and value-based reimbursement to pharmacies, oversight ensuring the SPBM and the FFS PBA comply with ODM’s expectations, improved provider and member satisfaction, and continuous improvement of the pharmacy program. 

ODM, SPBM, PPAC & MCO Responsibilities in the Future Ohio Medicaid Pharmacy Benefits Program

About the Ohio Medicaid SPBM & PPAC Procurements

In January 2021, ODM awarded the SPBM contract to Gainwell Technologies. Click here to read the full press release.

On April 14, 2021, ODM announced Myers and Stauffer as its PPAC vendor. Click here to read the full press release.

On Thursday, November 5, 2020, ODM released a RFP for a PPAC. The response period for this RFP closed on December 18, 2020. As a next step in this process, Ohio Medicaid will evaluate the responses to the RFP, and the applicants will be required to conduct oral presentations. Once oral presentations have concluded, a new managed care organization will be selected.

The RFP for this procurement is also available on the Request for Proposal page of medicaid.ohio.gov.

Prior to developing these RFPs, ODM released a Request for Information (RFI) for the SPBM procurement to gather input and suggestions from pharmacists, prescribers, and potential PBM bidders. The SPBM RFI responses received are available on the PBM RFI Responses page of medicaid.ohio.gov.  

Feedback received through the SPBM RFI was taken into consideration during the process of developing the RFP.