Pharmacy information

Pharmacy information for Ohio Medicaid plan

NOTE: For direction related to the MyCare Ohio plan, please refer to the “Pharmacy information for MyCare Ohio” section on this page.

Pharmacy benefits for enrolled members are managed through the Ohio Department of Medicaid (ODM). ODM has contracted with a single pharmacy benefit manager (SPBM) to improve the administration of pharmacy benefits for managed care recipients and ensure transparency, accountability, and integrity to better serve Ohio Medicaid members and their healthcare providers. The SPBM consolidates the processing of retail pharmacy benefits and maintains a pharmacy claims system that integrates with the Ohio Medicaid Enterprise System (OMES), new MCOs, pharmacies, and prescribers.

Please refer to the Preferred Drug List (PDL) when prescribing for our Medicaid members. This guide does not contain a complete list of drugs; rather, it lists the preferred drugs within the most commonly prescribed therapeutic categories.

Though most medications on the PDL are covered without prior authorization, a few agents will require you to contact our Pharmacy Department for authorization.

Single pharmacy benefit manager (SPBM) for Medicaid providers

The SPBM provides more pharmacy choices for members and offers a more streamlined process for providers with a single Preferred Drug List and uniform clinical criteria for coverage. SPBM services include:

• Processing pharmacy claims for all covered drugs dispensed by any pharmacy provider
• Providing expert clinical knowledge to establish Preferred Drug Lists (PDLs)
• Contracting with pharmacies to ensure members have easier access to medications

SPBM resources

Access Gainwell Technologies network 

Preferred drug list 

SPBM contact information

Prior authorizations can be submitted by phone, fax, or mail:

Phone: 833-491-0344
8 a.m. to 8 p.m. EST Monday to Friday

Fax: 833-679-5491

Mail: Gainwell Technologies OH SPBM,
P.O. Box 3908 Dublin, OH  43016-0472

Medical injectables for Medicaid providers

Provider administered drugs can be accessed via fax. The information presented in the provider administered pharmaceuticals fee schedule and prior authorization submission through fax pertains to medical drugs only when the provider plans to buy & bill.

Access provider administered drugs (buy & bill)

Fax: 800-563-5581

Provider Administered Pharmaceuticals Fee Schedule 

Medical Injectable resources

Prior Authorization Lookup Tool 

Clinical Criteria for medical injectables 

Forms 

Pharmacy information MyCare Ohio plan (MyCare Medicaid Only and Dual-Benefit)

Please refer to the formulary when prescribing for MyCare Ohio members. Though most medications on the formulary are covered without prior authorization, a few agents will require you to obtain an authorization.