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Resources for Pharmacists and Pharmacy Support Staff

On this page, pharmacists and pharmacy support staff, can find helpful information and guidance to prepare for the SPBM launch.

1. How to Contract with Gainwell

On October 1, Ohio Department of Medicaid’s (ODM) Single Pharmacy Benefit Manager (SPBM), Gainwell Technologies, began administering pharmacy benefits for the nearly 3 million Ohio Medicaid members enrolled in managed care. The SPBM initiative was designed and built to ensure transparency, accountability, and fairness.

In order to contract with Gainwell Technologies, your pharmacy must first be enrolled with ODM. Please visit the Ohio Medicaid Resources for Providers webpage for further information on enrollment with ODM.

Please refer to the Provider Manual on how to then contract with Gainwell.

If you have questions, please reach out to Gainwell Technologies LLC, Ohio Department of Medicaid Single Pharmacy Benefit Manager:

2. SPBM Web Portal Training

SPBM Web Portal Training Recording Now Available 

The recorded SPBM Web Portal training is now available for pharmacies and pharmacy support staff.  Viewing this training is important for pharmacists and their support staff to learn about the many tools available on both the public facing and secure portal.  The public facing portal includes access to reference material such as the Unified Preferred Drug List and criteria.  The secure portal requires log in credentials.  It provides access to specific patient information and the ability to reach the SPBM Clinical help desk via web chat. SPBM Clinical staff can also be reached via phone and email. 

To access the recording, please click here. Please use the same Learning Management System (LMS) credentials set up during your registration to log in.  

About the SPBM Web Portal

Find helpful information, resources, and links to recordings of Gainwell Technologies’ SPBM training sessions by navigating to the SPBM web portal and selecting the “Provider” tab. Under the provider tab, you will find the menu for “SPBM Web Portal Training.”

The public-facing SPBM web portal provides instant access to reference material such as the Unified Preferred Drug List (UPDL) and criteria, the Preferred Diabetic Supply List, the Specialty Drug List, and Quantity Limits List to assist with prescribing medications to Ohio Medicaid Managed Care members.   

The secure SPBM web portal requires the user to enter their credentials. This provides a way to check eligibility of Ohio Medicaid managed care members. It also enables prescribers to submit prior authorizations and view claim and prior authorization history. The portal also features a secure web chat to quickly speak with the SPBM help desk.

If you have any questions regarding SPBM Web Portal training, please email OH_MCD_PBM@gainwelltechnologies.com

3. Pharmacists: Updated Provider Manual  

What is the SPBM Provider Manual? 

On October 1, pharmacy benefits for managed Medicaid members are covered by the Single Pharmacy Benefit Manager (SPBM), Gainwell Technologies. Gainwell’s provider manual, also known as the pharmacy reference guide, is the primary resource guide providing key information to pharmacy providers, pharmacy support staff, and prescribers. The provider manual includes information related to pharmacy claims submission, reimbursement rates, pharmacy network requirements, the specialty pharmacy program, claims processing, utilization management, and prior authorization. 

How Do I Access the SPBM Provider Manual? 

The provider manual can be found here and on ODM’s Next Generation website under Provider Manual. The provider manual is updated periodically to reflect program changes or clarifications as necessary.  

For additional information about SPBM please visit ODM’s Next Generation website or the Gainwell Ohio Pharmacy website

4. Channel Management

With the implementation of the Single Pharmacy Benefit Manager (SPBM) on October 1, 2022, prescribers and pharmacists will experience changes in billing. Prescribers and pharmacists will bill to a different responsible party for Medicaid managed care prescription benefits beginning October 1, 2022.

Pharmacy Benefits Before and After October 1

As seen in the above graphic, pharmacists and prescribers will bill to the SPBM for prescriptions dispensed by pharmacy providers. Managed Care Organizations will cover pharmaceuticals from all other provider types. This typically entails provider-administered drugs. It is important to note that there will be no change to how to bill for fee-for-service members, and OhioRISE will cover behavioral health provider-administered drugs.

Please review the Provider Manual to understand new aspects of the next generation pharmacy program.

5. Specialty Pharmacy Information

Specialty Pharmacy Program Summary

As of October 1, Ohio Department of Medicaid’s (ODM) Single Pharmacy Benefit Manager (SPBM), Gainwell Technologies, is responsible for managing pharmacy services including a specialty pharmacy program for all Medicaid managed care members. Myers and Stauffer, the Pharmacy Pricing and Audit Consultant (PPAC), in collaboration with ODM, provides oversight of the specialty pharmacy program. All Medicaid specialty pharmacy medications and claims will be subject to the following contracting and reimbursement processes.

Specialty Pharmacy Contracting

Pharmacies that wish to fill specialty medications must agree and attest to the following conditions:

  • Obtain and maintain an active specialty pharmacy or home care accreditation from one of the following organizations:
    • The Joint Commission.
    • Utilization Review Accreditation Commission (URAC).
    • Accreditation Commission for Health Care (ACHC).
  • Provide SPBM with direct contacts and contact information for pharmacy staff responsible for coordinating resolution of escalated issues and clinical pharmacy issues.
  • Access to a nurse or pharmacist by telephone 24 hours per day, seven days per week, 365 days per year for individuals served by our managed care plan partners.
  • Acceptance of reimbursement rates set by plan sponsor. In support of that, the pharmacy agrees to participate in all pricing surveys.
  • Expedited delivery to individuals served by our managed care plan partners when clinically necessary.
  • Adherence to all SPBM specialty program requirements delineated in the current provider manual of plan sponsor and participation in all SPBM utilization management strategies.

Specialty Pharmacy Reimbursement

Myers and Stauffer, the Pharmacy Pricing and Audit Consultant (PPAC), will assist in overseeing the transparency and accuracy of the specialty pharmacy program as managed by the SPBM. PPAC has implemented the Ohio Average Acquisition Cost (OAAC) survey to accurately reimburse enrolled pharmacies based on average acquisition cost (when available) plus a dispensing fee for brand, generic, and specialty drugs.

  • Dispensing Fee Tier
    • If more than 5% of a pharmacy’s dispensed prescriptions are specialty medications, it will automatically be assigned to the highest tier, Tier C, and a base dispensing fee of $10.50.
  • Specialty Drug Reimbursement
    • Ingredient Cost
      • SPBM will apply the “lesser of” logic to specialty drug ingredient cost, which includes:
        • Ohio Average Acquisition Cost (OAAC).
        • Wholesale Acquisition Cost (WAC).
        • National Average Drug Acquisition Cost (NADAC).
        • Usual and Customary (U&C).
    • Dispensing Fee for Medications Appearing on the Specialty Drug List
      • Base dispensing fee + $46.25.
  • Clotting Factor Reimbursement
    • Ingredient Cost (lesser of):
      • OAAC.
      • U&C.
    • Dispensing Fee for Clotting Factor Products
      • Base dispensing fee + $400.

Specialty Pharmacy Drug List

The ODM specialty pharmacy drug list is updated weekly and can be found at the following locations:

Additional Information

Additional information on provider enrollment and contracting, pharmacy billing information, and the provider manual can be found under the Provider tab at Home page - OH MCD SPBM.Web (ohio.gov)

Questions?

If you have questions about the contracting process or require additional information, please contact Gainwell Technologies by phone at: 1-833-491-0364 or by email at: OH_MCD_PBM_network@gainwelltechnologies.com.

6. Next Generation Member ID Cards

Pharmacists should be aware that all Ohio Department of Medicaid (ODM) managed care members received a new member ID card in the mail prior to October 1, from their managed care organization (MCO). This new card will reflect that, beginning October 1, pharmacy benefits for members enrolled in managed care will be covered by the Single Pharmacy Benefit Manager (SPBM), Gainwell Technologies.

Pharmacy benefits will no longer be provided by individual MCOs. Please continue to bill pharmacy services to the member’s original assigned payer (fee-for-service (FFS) or MCO PBM) until October 1. Reversals for claims originally billed before October 1 should be also sent to the original payer.

After October 1, Gainwell Technologies should be billed. If a member does not have a Medicaid ID card, a pharmacy can verify coverage in MITS with the member’s demographic information. Please see the Next Generation ID Card FAQ for more information or visit the SPBM provider portal.

In addition to a new design that features the Next Generation logo, the card will include contact information for Gainwell Technologies and the ODM Integrated Help Desk.

If members have questions about the new card, please direct them to contact their MCO.

Additional details about the new member ID cards can be found on the Resources for Individuals page of the Next Generation website.

7. Prior Authorizations

Prior authorization is the process of obtaining additional information from the prescriber of a medication or service for the purpose of ensuring eligibility, benefit coverage, medical necessity, location, and appropriateness of services.

Prior authorization requests are accepted via toll-free telephone, facsimile, web portal, or mail.

Prior authorization phone number

1-833-491-0344

Prior authorization fax number

1-833-679-5491

Prior authorization web portal

https://spbm.medicaid.ohio.gov

Prior authorization mail address

PO BOX 3908 Dublin, OH 43016-0472

Prior Authorization Contact Information

Requests are submitted utilizing prior authorization forms specified by ODM which are available via the Gainwell Technologies public portal located at: https://spbm.medicaid.ohio.gov under “Reference Material” then “Useful Links” and then “Forms”, or fax-on-demand.

Learn more about prior authorizations by reviewing the SPBM Provider Manual.

8. Pharmacy Reimbursement

The Provider Manual and the Pharmacy and Pricing Audit Consultant (PPAC) – Ohio Medicaid website contains information regarding pharmacy reimbursement.

9. Claims Dispute Resolution Process

The Provider Manual contains information regarding the adverse determination process.