AmeriHealth Caritas Ohio provides coverage and reimbursement for covered outpatient provider administered drugs, as indicated by benefits, and approved per applicable criteria, except for those supplied by a pharmacy (Provider Type 70 that are payable through the SPBM) and those that are reimbursed by OhioRISE.
Prior authorization requests for medications covered under the outpatient medical benefit should be submitted to:
- PerformRx: 1-855-662-0279
- The AmeriHealth Caritas Ohio Provider Portal
Ohio’s Single Pharmacy Benefit Manager (SPBM) is a specialized managed care program operating as a prepaid ambulatory health plan (PAHP) that will provide pharmacy benefits for the entire Medicaid managed care population (excluding MyCare Ohio members). ODM has selected Gainwell Technologies to serve as the SPBM. Information on Ohio’s SBPM, Gainwell, is available in the following locations:
- Page 123 of the Provider Manual (PDF)
- The Gainwell Member Portal
- The Ohio Department of Medicaid pharmacy website
Gainwell utilizes the Ohio Medicaid Unified Preferred Drug List (UPDL). The drug benefit has been developed to cover medically necessary prescription products. The pharmacy benefit design provides for outpatient prescription services that are appropriate, medically necessary, and not likely to result in adverse medical outcomes. The formulary and UPDL are available on Gainwell’s website.