Pharmacy and Prescription Benefits

Ohio's Single Pharmacy Benefit Manager (SPBM) will begin providing pharmacy services across all managed care plans and members beginning in October 2022. The Ohio Department of Medicaid has contracted with Gainwell Technologies to be the SPBM.

Gainwell covers all Medicaid-covered, medically necessary prescription and over-the-count (OTC) medications. They use a preferred drug list (PDL) which is a list of drugs we prefer your provider prescribe. They may require your prescriber to submit a prior authorization request, which is where your prescriber would provide us additional information explaining why a specific medication and/or a certain dose or quantity of medication may be required.  The below services are available to you to support any additional needs you may have:

  • Oral interpretation.
  • Translation services.
  • Auxiliary aids and services.
  • Written information in alternative formats including braille and large print.

Preferred drug list

Gainwell uses a PDL which is a list of drugs they prefer your provider prescribes. You can find a copy of the PDL in the following locations:

Prior authorizations 

Your prescriber may be required to submit a prior authorization request for certain medications. These requests will be sent by your prescriber through many different routes (phone, fax, mail, or web portal) to ensure a quick and efficient review of your medication. In these circumstances, your provider will send an authorization request to the Gainwell Pharmacy Services team, where they will complete a clinical review of the medication your provider is requesting. Gainwell Pharmacy Services team will work closely with your prescriber to provide the best clinical decision. You will receive a letter in the mail with the outcome of the decision made.

If you do not agree with the decision that is made by Gainwell, you will be sent detailed information on how you can appeal our decision.

You have the option to call Member Services toll free at 1-833-491-0344 (TTY 1-833-655-2437) to obtain information regarding the PDL, medications that may require prior authorization, or to ask any medication related questions you may have. The PDL and a list of medications that require prior authorization are available for you to access online at: https://spbm.medicaid.ohio.gov. It is important that you and/or your prescriber reference the PDL and/or the list of medications that require prior authorizations each time you have questions, as these are documents that can change.

Pharmacy utilization management strategies

The PDL will be used with each prior authorization review that is completed by the Gainwell Pharmacy Services team. When a prior authorization is required, Gainwell must approve the prescriber’s request before you will be able to fill your medication at your preferred, in-network pharmacy. A prior authorization may be required if:

  • A generic or pharmacy alternative drug is available.
  • The requested drug can be misused/abused.
  • Other medications must be tried first.
  • Quantity limits for the requested medication have been exceeded.
  • The medication your provider has prescribed is not included on the PDL.

The PDL usually includes multiple medication options for treating a particular condition. These different drugs are referred to as “alternative” drugs and are just as effective as other drugs with no additional side effects or health problems.

Specific reasons your prescriber may be required to submit a prior authorization request include:

  • Step Therapy – In some case, our plan requires you first try certain drugs to treat your medical condition.
  • Generic Substitution – This is where a pharmacy will be required to provide a generic drug in place of a brand-name drug when available. Generic drugs are just as safe and effective as brand name drugs and should be prescribed first.
  • Therapeutic Interchange – This is where you are unable to take a medication for reasons like an allergy, intolerance, etc., a medication might not work for you and your prescriber may write a prescription for a medication that is not on the approved drug list.
  • Specialty Medications – This is a review of a medication that is considered more complex for a specific disease and requires specific attention and handling during the prior authorization review process. For these medications, you may have to get them through a specialty pharmacy. Your prescriber will work with Gainwell Pharmacy Services to make sure you can obtain the medication you need as quickly as possible.

Excluded services

Gainwell will not pay for the following categories that are not covered by the Ohio Medicaid pharmacy program:

  • Drugs for treatment of obesity.
  • Drugs for treatment of infertility.
  • Drugs for the treatment of erectile dysfunction.
  • DESI drugs or drugs that may have been determined to be identical, similar, or related.
  • Drugs that are eligible to be covered by Medicare Part D.
  • Over-the-counter drugs that are not listed in accordance with paragraph C of OAC rule 5160-9-03.
  • Drugs being used for indications not approved by the Food and Drug Administration (FDA) unless supported by compelling clinical evidence.

Additional services

The Gainwell Pharmacy team can also assist you with the below services by calling our member help desk at 1-833-491-0344 (TTY 1-833-655-2437). You can also access this information on your member portal by logging in at https://spbm.medicaid.ohio.gov

  • Locating a pharmacy to fill the prescription you were given by your provider.
  • Verifying you have active pharmacy coverage.
  • Obtaining diabetic supplies covered through your pharmacy benefit.
  • Obtaining durable medical equipment (DME) covered through your pharmacy benefit.

Requests for appeals, grievances, or state hearings

Grievance

If you are unhappy with anything in relation to Gainwell Pharmacy Services or our providers, please contact us as soon as possible. This is called a grievance.

To contact us you can:

  • Call Gainwell Member Services at 1-833-491-0344 (TTY 1-833-655-2437) and choose option 1 to speak with a Gainwell Pharmacy Help Desk team member.
  • Fill out the Grievance/Appeal form included in this member handbook and mail to Gainwell Pharmacy Services at the address below or online through your member portal.
  • Visit our website at https://spbm.medicaid.ohio.gov.
  • Write a letter telling us you are unhappy. Please be sure to include your first and last name, your Medicaid ID, your address, and your telephone number so we are able to contact you, if needed. You can submit your form or letter via email or mail.

Gainwell Pharmacy Services
5475 Rings Rd., Suite 125
Dublin, OH 43017-7565

Once you contact Gainwell to submit your grievance, we will follow up with you by telephone, mail delivery, or other appropriate means with the below timeframes:

  • Two (2) working days for grievances about not being able to get medications you need.
  • Thirty (30) calendar days for all other grievances.

Appeal

If you receive a notice from us that you disagree with, you may ask for an appeal within sixty (60) calendar days after the date of the notice. Gainwell will provide you with an answer to your appeal within fifteen (15) calendar days from the date you contacted us. If you believe fifteen (15) calendar days could seriously jeopardize your life, physical or mental health or ability to attain, maintain, or regain maximum function, contact Gainwell Member Services at the number listed below as soon as possible to expedite your review process. To request an appeal, you can:

  • Call Member Services at 1-833-491-0344 (TTY 1-833-655-2437) and choose option 1 to speak with a Gainwell Pharmacy Help Desk team member.
  • Fill out the Grievance/Appeal form included in this member handbook and mail to Gainwell Pharmacy Services at the address below, or complete online through your member portal
  • Visit our website at https://spbm.medicaid.ohio.gov.
  • Write a letter. Please be sure to include your first and last name, Medicaid ID, your address, and your telephone number so we are able to contact you, if needed. You can submit your form or letter via email or mail.

Gainwell Pharmacy Services
5475 Rings Rd., Suite 125
Dublin, OH 43017-7565

When submitting an appeal, please include the following information:

  • Your name and Medicaid ID number on your card.
  • Your prescriber’s name.
  • The reason you disagree with the outcome provided by Gainwell.
  • Any documentation or information to support your request to have your decision overturned.

Gainwell must provide you with an answer to your appeal within fifteen (15) calendar days from the date you contact us. If we do not change our decision, you will be notified in writing and will be provided your right to request a State hearing. You must complete the appeal process before you are able to request a State hearing.

If we need more time to make a decision for either a grievance or appeal, we will send you a letter telling you we need to take up to fourteen (14) more calendar days. That letter will also provide you with information as to why we need more time to complete your request.

State hearing

You must complete the Gainwell appeal process before you are able to request a State hearing. A State hearing is a meeting with you or your authorized representative, someone from the County Department of Job and Family Services, someone from Gainwell, and a hearing officer from the Bureau of State Hearings within the Ohio Department of Job and Family Services (ODJFS). During this meeting, you will explain why you think Gainwell Pharmacy Services did not make the right decisions and Gainwell will explain the reasons for making our decision. A decision will be made by the hearing officer based on rules, regulations, and information provided during the hearing.

You will be notified of your right to request a State hearing if we do not change our decision as a result of appeal to Gainwell. If you would like to request a State hearing, you or an authorized representative must request a hearing within ninety (90) calendar days of your denied appeal from Gainwell.

To request a hearing, you can sign and return the State hearing form to the address or fax number listed on the form, call the Bureau of State Hearings at 1-866-635-3748 (TTY/TDD 614-728-2985), or submit your request via email to bsh@jfs.ohio.gov. If you want information on free legal services, you can call the Ohio State Legal Services Association at 1-800-589-5888 for the local number to your legal aid office.

State hearing decisions are usually issued no later than seventy (70) calendar days after the request is received. If it is determined that the health condition meets the criteria for an expedited decision, the decision will be issued as quickly as needed but no later than three (3) business days after the request is received. Expedited decisions are for situations when the standard review time frame could seriously jeopardize your life or health or ability to attain, maintain, or regain maximum function.

Pharmacy access

Gainwell Pharmacy Services offers a member portal for you to log in and manage your pharmacy needs. To log in to your personal member portal, visit https://spbm.medicaid.ohio.gov and log in with your personal information that you have set up for your account.

To sign up for a provider through the Gainwell Member Portal, you can follow the directions on the website at https://spbm.medicaid.ohio.gov or call your Member Services toll free at 1-833-491-0344 (TTY 1-833-655-2437) to speak with a Gainwell Pharmacy Services agent to receive step-by-step assistance to sign up for access.

Emergency outpatient drug

In the event of an emergency situation, you will have the option to receive a 72-hour (3 day) supply of your medically necessary medication. If you have difficulties with this process, please contact Gainwell Pharmacy Services at 1-833-491-0344 (TTY 1-833-655-2437)

Non-discrimination statement

Gainwell Pharmacy Services follows State and Federal civil rights laws that protect you from discrimination or unfair treatment. We do not treat people unfairly because of a person’s age, race, color, national origin, religion, gender, gender identity, sexual orientation, marital status, mental or physical disability, medical history, health status, genetic information, evidence of insurability, military status, veteran status, ancestry, the need for health services to receive any covered services or geographic location.

Gainwell has no moral or religious objections to services that we provide for Ohio Department of Medicaid members.

If you are in need of any additional services below, please contact Gainwell Member Services toll free at 1-833-491-0344 (TTY 1-833-655-2437) to speak to a team member at no additional charge:

  • Oral interpretation.
  • Translation services.
  • Auxiliary aids and services.
  • Written information in other languages, including, but not limited to, Spanish, Somali, and Arabic.
  • Written information in alternative formats including, but not limited to, braille and large print.

Provider network statement

Gainwell works with pharmacies to fill prescriptions close to your home for easy access to any of your medication needs. Many of the pharmacies offer services including prescription home delivery, medication management and assistance if you have limited English, hearing or sight difficulties, or a disability needing extra support. Specialty pharmacies also are available to provide medications with specific handling, storage, and distribution requirements to treat high risk, complex, or rare disease (s). If there are any changes to these pharmacies, we will be sure to let you know via the website, Gainwell Member Portal, or mailings as determined by your preferred communication request.

Gainwell does not cover prescription fills at pharmacies that are not signed up (Out of Network) to dispense medications for Ohio Medicaid members, which includes, but is not limited to, pharmacies that are far away from your home, except for emergency situations (if out of the State in an emergency or if an Ohio pharmacy cannot supply the medication).

Pharmacy provider network

You can obtain information on how to locate a pharmacy covered in your network by accessing the Pharmacy Provider Directory online at https://spbm.medicaid.ohio.gov or through logging in to your Gainwell Member Portal at https://spbm.medicaid.ohio.gov.  You can request a paper copy of the Pharmacy Provider Directory by calling Gainwell Member Services toll free at 1-833-491-0344 (TTY 1-833-655-2437).