Prior authorization requirements

Prior authorization requests and forms

Prior authorization lookup tool 

Prior authorization forms 

Ohio Medicaid Managed Care Nursing Facility Request Form 

 Services Requiring Prior Authorization

 Substance Use Disorder Services Prior Authorization Form

 Uniform Prior Authorization Form 2023

 Urine Drug Testing Prior Authorization Form

 Floor to skilled nursing facility (SNF) provider process

Medicaid Provider Resources

OhioRISE

OhioRISE (Resilience through Integrated Systems and Excellence) is a specialized managed care program for youth with behavioral health and multi-system needs. Aetna Better Health of Ohio will serve as the single statewide specialized managed care plan. For more information on OhioRISE, call their toll-free number, contact your provider services representative, or visit their site at AetnaBetterHealth.com/OhioRISE, or via phone.

Contact OhioRISE

 833-711-0773

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
• Provide expert clinical knowledge to establish Preferred Drug Lists (PDLs)
• Contract with pharmacies to ensure members have easier access to medications

For more information about the SPBM, call their phone number, contact your Provider Services representative, refer to your provider manual, or visit the Ohio Department of Medicaid's site.

Learn more about the SPBM 

Contact SPBM

 833-491-0344

MyCare Ohio Provider Resources

Coming soon.

Pharmacy

For information about pharmacy related prior authorizations, you may call directly, contact your Provider Services representative, refer to your provider manual, or submit your request online.

Submitting and Checking Prior Authorization (PA) Requests for Ohio Medicaid Plans

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.

Authorization inquiries, prior authorization and notification requests for Medicaid can be made through one of these options:

• SPBM Phone: 833-491-0344 (TTY 711)
• SPBM Fax: 833-679-5491
• Online: Ohio Medicaid Pharmacy Services Website 

Submitting and Checking Prior Authorization (PA) Requests for MyCare Ohio Plans

Providers can submit prior authorization (PA) or coverage determination requests for MyCare Ohio members electronically, by phone, or by fax.

Electronic Prior Authorization (ePA)
 

Providers can submit requests by logging into the CarelonRx Provider Portal or by submitting the request to CoverMyMeds^® or Surescripts® . These tools allow providers to:

• Submit required clinical documentation online
• View updates on the status of requests

Phone or Fax Options
 

Requests and inquiries can also be made by:

• Phone: 833-293-0661 (TTY 711)
• Fax: 1-844-521-6938

Information Needed to Check a PA Status
 

When checking the status of a PA request, providers should have:

• Patient/member ID number
• Prescription drug name
• Prescriber information
• Date the PA request was submitted

Medical injectables for Medicaid providers
 

Authorization inquiries, prior authorization and notification requests for medical injectables can be made through one of these options:

• Phone: 833-727-2170 (TTY)
• Fax: 800-563-5581
• Online: Availity.com