REMINDER: July 1 Medicaid pharmacy fee for service transition to Gainwell Technologies
What you need to know.
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 pharmacies one vendor to work with regardless of how their patients are enrolled in Medicaid.
Impact to prescribers and pharmacies.
Beginning July 1, Medicaid FFS pharmacy claims should be submitted to Gainwell with the BIN of 024251, a PCN of OHRXPFFS, and the same 12-digit Medicaid ID number used to bill FFS today. All ODM-enrolled pharmacies will be able to submit FFS claims. No separate contracting with the SPBM is required.
Additionally, prior authorization management will also transition to Gainwell beginning July 1. On this date, prescribers should begin submitting prior authorization requests to Gainwell, using the same forms and processes as used under the SPBM managed care program. All active prior authorizations on file with Change Healthcare will be transferred to Gainwell and will be honored through their original expiration date.
Pharmacies and pharmacists can find the FFS Pharmacy Reference Guide and Payer Sheet at: Ohio Medicaid Pharmacy FFS Billing Information. Also available is ODM’s pharmacy fee for service provider FAQ for your reference.
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.
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:
- FFS Pharmacy claims processing.
- FFS Pharmacy prior authorizations.
- FFS Pharmacy claims review.
- FFS Drug utilization review.
- Payment to pharmacies under the FFS program.
- FFS Member and provider customer service.
If you have questions about the upcoming transition or the Medicaid pharmacy program, please email MedicaidSPBM@medicaid.ohio.gov.
Ohio Department of Medicaid