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Dear Ohio Medicaid Providers,
Building on the success of the Next Generation program, Ohio Department of Medicaid (ODM) is transitioning pharmacy benefits for Medicaid Fee-for-Service (FFS) enrollees to our single pharmacy benefits manager (SPBM) on July 1. This transition consolidates oversight of Medicaid pharmacy benefits for managed care and FFS members, giving prescribers and providers one vendor to work with regardless of how their patients are enrolled in Medicaid.
Since October 1, 2022, Gainwell Technologies has served as the SPBM for Ohio Medicaid’s managed care population. Beginning July 1, Gainwell will be responsible for:
- Pharmacy point of sale system support.
- Pharmacy prior authorizations.
- Pharmacy claims processing.
- Pharmacy claims review.
- Drug utilization review.
- Payment to pharmacies.
- Member and provider customer service.
- Clinical quality and utilization management.
Impact to FFS Medicaid enrollees
Individuals enrolled in Medicaid FFS should experience no change to their pharmacy benefit. FFS enrollees will have access to the same pharmacies and medications as they do today. They will be asked to carry new ID cards, but their individual IDs will remain the same.
Additionally, any medication prior authorization that is in place or submitted before July 1 will be honored through its original expiration date.
Impact to prescribers and pharmacies
Beginning July 1, Medicaid FFS prescribers and pharmacies will route claims to Gainwell’s new BIN 024251 and PCN OHRXPFFS. This information will be included on the new FFS member ID cards, yet, as mentioned above, they will retain their current member ID numbers.
Pharmacies and pharmacists can find the FFS Pharmacy Reference Guide and Payer Sheet at: Pharmacy Billing Information | pharmacy.medicaid.ohio.gov.
If you have questions about the upcoming transition or the Medicaid pharmacy program, please email MedicaidSPBM@medicaid.ohio.gov.
Thank you,
Ohio Department of Medicaid
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