Welcome to
Ohio Medicaid
Pharmacy Services

Supported by Gainwell Pharmacy Services.
Did you know?

Intentionally charging for medications not actually dispensed and knowingly submitting the claim for payment is fraud.

Unnecessary prescription refills that Medicaid Members do not use wastes healthcare resources?

Prescribing brand-named drugs without option to trial lower cost options can be considered abuse.​


06/01/2025

The Ohio Department of Medicaid will be changing the Preferred Diabetic Supply List (PDSL) on June 1, 2025. Effective for claims with an adjudication date of June 1, 2025 and beyond, the following LifeScan, Inc. glucose meters and test strips will no longer be covered products:

  *   OneTouch Ultra 2 Meter
  *   OneTouch Verio Flex Meter
  *   OneTouch Ultra Blue Test Strip
  *   OneTouch Verio Test Strip

Members are directed to transition to the following products:

  *   TrueMetrix Meter
  *   TrueMetrix Air Meter
  *   Relion TrueMetrix Air Meter
  *   TrueMetrix Test Strips
  *   Relion TrueMetrix Test Strips
  *   Accu-Chek Guide Meter (Effective 6/1/2025)
  *   Accu-Chek Guide Test Strips (Effective 6/1/2025)

If you have any questions regarding this communication, please call Gainwell Pharmacy Services at 1-833-491-0344.​




09/01/2024

Effective 09.01.2024, the medications below will require a prior authorization (submitted by your prescriber) if there is not already an active prior authorization on file:

  • Bydureon Bcise (exenatide)
  • Mounjaro (tirzepatide)
  • Ozempic (semaglutide)
  • Rybelsus (semaglutide)

Prescribers may submit a prior authorization by electronic request, by faxing Gainwell Pharmacy Services at 833-679-5491, or by calling 833-491-0344 (TTY 833-655-2437). Prior authorizations are processed within 24 hours of receipt.

Prior authorization submissions for the medications above will be reviewed per the Ohio Medicaid Unified Preferred Drug List (UPDL) clinical criteria. You can find more information about prior authorizations for these medications by visiting https:\\spbm.medicaid.ohio.gov. Choose “Reference Material", then “Unified Preferred Drug List", and then “UPDL criteria effective 07.01.2024" from the list of documents.



06/30/2023

Beginning on July 1, 2023, in addition to Ohio Medicaid Managed Care, Gainwell Technologies will be the Single Pharmacy Benefit Manager (SPBM) for Ohio Medicaid Fee for Service. ODM's continued goal for the SPBM are to improve management and administration of pharmacy benefits for Ohio Medicaid managed care members. Through the SPBM, ODM gains increased accountability and ensures alignment with clinical and policy goals, while also improving transparency.

A Frequently Asked Questions (FAQ) for pharmacies servicing FFS members is available here: SPBM FFS Provider FAQ



06/30/2023

Are you a pharmacy or prescriber having issues registering for the secure SPBM Web Portal?  Gainwell is offering several options available below for your assistance:

  • Single Pharmacy Benefit Manager (SPBM) Secure Web Portal Provider Registration FAQ is available here
  • Provider Registration Manual is available here.
  • Provider Registration Process training video is available here.​


06/30/2023

The SPBM Web Portal training recording is now available for all enrolled Ohio Medicaid Members!  

For Member training registration instructions, click here.  

If you have any questions regarding SPBM Web Portal training, please email OH_MCD_PBM@gainwelltechnologies.com




06/30/2023

Pharmacy Web Portal training recording now available

The recorded SPBM Web Portal training is now available for pharmacies and pharmacy support staff.  Viewing this training is important for pharmacists and their support staff to learn about the many tools available on both the public facing and secure portal.  The public facing portal includes access to reference material such as the Unified Preferred Drug List and criteria.  The secure portal requires log in credentials.  It provides access to specific patient information and the ability to reach the SPBM Clinical help desk via web chat. SPBM Clinical staff can also be reached via phone and email.

To access the recording, please click here. Please use the same Learning Management System (LMS) credentials set up during your registration to log in.​

Prescriber Web Portal training recording now available

The recorded SPBM Web Portal training is now available for prescribers and prescriber support staff.  Viewing this training is important for pharmacists and their support staff to learn about the many tools available on both the public facing and secure portal.  The public facing portal includes access to reference material such as the Unified Preferred Drug List and criteria.  The secure portal requires log in credentials.  It provides access to specific patient information and the ability to reach the SPBM Clinical help desk via web chat. SPBM Clinical staff can also be reached via phone and email.

To access the recording, please click here​. Please use the same Learning Management System (LMS) credentials set up during your registration to log in.​




12/27/2022

Ohio SPBM Prescribers, When submitting a prior authorization (PA) request via fax or mail, the prescriber is required to use the prior authorization forms found on the SPBM portal and must include the member's 12-digit Medicaid ID (also known as the “Member ID" on the member's ID card) in the document header. Failure to do so will not allow the system to appropriately associate the authorization with the member. Starting 2/10/2023, Gainwell Technologies SPBM will no longer accept PAs without the correct 12-digit Medicaid ID. Please direct questions to Gainwell Technologies Help Desk at 833-491-0344.



10/01/2022

Gainwell Technologies and the Ohio Department of Medicaid (ODM) launched the Single Pharmacy Benefit Manager (SPBM) on October 1! Gainwell has already contracted with more than 2600 pharmacies. ODM's goals for the SPBM are to improve management and administration of pharmacy benefits for Ohio Medicaid managed care members. Through the SPBM, ODM gains increased accountability and ensures alignment with clinical and policy goals, while also improving transparency.

Questions?

Pharmacy providers and members may contact the Gainwell Customer Support Center by phone 833-491-0344, 24 hours a day, seven days a week. The Customer Support Center is closed on Thanksgiving Day and Christmas. ​

​Managed Care Entity Web Portal training recording now available

The recorded SPBM Web Portal training is now available for Managed Care Entity Portal Administrators and staff. Viewing this training is important for managed care entities to learn about the many tools available on both the public facing and secure portal. The public facing portal includes access to reference material such as the Unified Preferred Drug List and criteria. The secure portal requires log in credentials that will allow access to specific patient information. The portal also gives the user the ability to reach the SPBM Clinical help desk via web chat.

To access the recording, please click here . Please use the same Learning Management System (LMS) credentials set up during your registration to log in. ​​​





05/0​1/2022

Welcome to the new Ohio Medicaid pharmacy services online portal.

This is a soft launch of the SPBM online portal with limited fea​tures.

Thank you for your patience as we continue to enhance the system. ​​



  • General
  • Member
  • Provider
  • MCE
  • Program Integrity

Welcome to Ohio Medicaid Pharmacy Services Online Portal

Sample Image
This website provides information to members, pharmacies, prescribers, Managed Care Entities, and the public. Users may find helpful website links and documents within our online portal in the menu bar above.
Members
Log in to the member secure portal to view your:

  • Medicaid claims and notifications
  • Medicaid programs and benefits
  • Directory of providers
Providers / Trading Partners
Login to the provider secure portal to:

  • View Medicaid eligibility and history
  • Submit claims
  • Submit authorization requests
  • Check document status
  • Resume provider enrollment application
  • Check provider enrollment application status
  • How to Apply for Medicaid
  • Medicaid Card Information
  • Medicaid Member Handbook
  • Specialty Pharmacy Directory
  • Privacy Practices
  • Member SPBM Web Portal Training
  • Member Pharmacy FAQs
  • Pharmacy Directories
You may apply for Medicaid benefits by:
  • Going to Ohio Benefits
  • You can also call or visit your local county office for help with benefits at 1-844-640-OHIO (6446). TTY: 711
Gainwell Pharmacy Services follows state and federal civil rights laws that protect you from discrimination or unfair treatment. We do not treat a person differently because of a person’s age, race, color, national origin, religion, sex, gender identity, sexual orientation, marital status, mental or physical disability, medical history, health status, genetic information, evidence of insurability, or geographic location. If you would like to file a complaint about unfair treatment, or for any other reason, please contact Gainwell by mail, phone, or email at:​

Gainwell Pharmacy Services
5475 Rings Rd.
Atrium II North Tower, Suite 125
Dublin, Ohio 43017-7565
OH_MCD_PBM@GainwellTechnologies.com​
If you are enrolled in Managed Care, you will receive a card from your managed care plan.​
You can access the Member Handbook here​.
Your guide to Medicaid and other information about your Medicaid benefits can be found in the Member section of the Medicaid Managed Care Plan websites.​​​

The Specialty Accredited Pharmacy Lists are available here​.
The Gainwell Notice of Privacy Practices is available here​.​​

Register today for SPBM Web Portal training!

Registration for SPBM Web Portal training is now open for all members.

Please join the Gainwell Ohio SPBM training staff to learn the difference between the public and the secure portals, including how to register for the secure portal. During the training, you will also learn about many exciting tools available on the SPBM Web Portal such as member eligibility, viewing prior authorization status, the ability to quickly speak with the SPBM help desk, and much more!

Members will have access to a training video on Oct. 1.  For training registration instructions, click here​.​​


The Member Pharmacy FAQs is available here​.​​
  • Portal Registration
  • Provider Enrollment and Contracting
  • Pharmacy Billing Information
  • Specialty Pharmacy Directory
  • Provider Manual
Any provider (prescriber or pharmacy) that wishes to use the Portal to exchange PHI will be required to register as a trading partner. Pharmacies and prescribing providers must be enrolled with Ohio Medicaid prior to registering as a trading partner. Trading partner account registration/activation enables access to the secure provider portal for direct data entry of claims and prior authorizations, member eligibility inquiries, claim status inquiries, remittance advice, and more. Registration will begin Fall 2022.​​
Before beginning the enrollment or re-enrollment process, gather all information needed to complete an application. A detailed description of how to complete each of the enrollment steps and a list of information to have on hand before starting the enrollment application is available at: Provider Enrollment.

The Provider Network Management (PNM) module is going live in parallel with the Single Pharmacy Benefit Manager (SPBM) on Oct. 1. PNM will replace MITS provider enrollment and provider data management. This launch also includes a new requirement to establish an OH|ID to access any of ODM's Ohio Medicaid Enterprise Systems (OMES).

To allow providers an advanced opportunity to set up their OH|ID and associate their accounts, ODM has launched a PNM pre-registration site at: https://pnm-preregistration.omes.maximus.com​. The PNM Pre-Registration tool is available until Sept. 23 and will ease the transition and prevent disruptions to system access for providers ahead of go-live on Oct. 1. Additionally, PNM training is now available for providers in a variety of formats, including virtual, in-person, and self-paced. Please access this job aid for step-by-step instructions to sign up for a session.

For further information regarding network contracting with Gainwell, please contact us at OH_MCD_PBM_Network@gainwelltechnologies.com​.​

Payer sheet is available here.​​​

835 Job Aide is available here​.
The Specialty Accredited Pharmacy Lists are available​ here​.
The Provider Manual, also known as the ​Pharmacy Reference Guide, is available here.​​​
  • MCE

Managed Care Entities (MCE) including Managed Care Organizations (MCO) and the Prepaid Inpatient Health Plan (PIHP), which is also known as OhioRISE, will be given access to the SPBM online portal to view clinical profile information about members that are actively enrolled in their associated MCE.

Clinical information that is available includes member benefit and eligibility, pharmacy prescription claims activity, Rx prior authorizations, and Coordinated Services Program (CSP) status will be distributed to the MCEs, however, the portal will allow quicker access to the most current information. ​


  • Welcome
  • Special Investigation Unit
  • Regulatory Compliance
  • Report Fraud Waste or Abuse
  • FAQ
  • Policies & Resources
Gainwell is committed to protecting the integrity of the Ohio Medicaid Program.  The Gainwell Ohio Single Pharmacy Benefit Manager (SPBM) Program Integrity team welcomes you to browse our page and resources. 

We are here to support members, providers, and managed care entities in resolving and reporting fraud, waste, and abuse (FWA) and all matters of noncompliance. 

Medicaid FWA negatively impacts our members, providers, and our community, which is why we have invested in and devoted experienced anti-fraud professionals to prevent, detect, and deter FWA. 

Our team will respond promptly to reports of potential fraud, waste, or abuse activities.  In partnership and collaboration with Medicaid members, pharmacies, managed care entities, and subcontractors we strive to deliver Ohio’s Medicaid Pharmacy Benefits in accordance with all applicable federal and state regulatory requirements.
​​​
Our Special Investigations Unit is an important part of our program integrity efforts.  Our SIU team works to prevent, detect, correct, and deter healthcare fraud, waste, and abuse.  These efforts in turn help to avoid unnecessary drug costs while ensuring appropriate utilization for Ohio Medicaid Members, the Ohio Medicaid Program, and the Ohio Community.  

SIU has procedures in place to promptly address potential fraud, waste, and abuse of Medicaid funds as well as addressing non-compliance with federal and state requirements.

In addition to investigating and reporting identified issues to appropriate authorities, our SIU team also provides proactive reviews, provider education, and corrective action plans to help ensure appropriate use of Medicaid funds and services.​​
An important part of Gainwell’s commitment protecting the integrity of the Ohio Medicaid Program is our dedication to compliance and ethics. Our Compliance team is dedicated to supporting members, providers, and managed care entities in resolving matters of noncompliance and ensure that Ohio Medicaid pharmacy benefits are provided in accordance with federal and state program requirements.

We highlight the importance of compliance and ethics to our employees through our Code of Conduct, Compliance Plan, training, and employee outreach activities. 

We strive to maintain a culture of compliance and value doing the right thing all the time.  Our compliance processes are in place to ensure our business is conducted in compliance with all applicable federal, state, and local laws and regulations.

Should you find areas of compliance concerns, please do not hesitate to reach out to us.  ​

Report Fraud Waste and Abuse

Compliance Hotline: 1-833-220-9970
Website: https://spbm-medicaid-ohio.ethicspoint.com/
Email: OH_MCD_Compliance@GAINWELLTECHNOLOGIES.COM

All reports are investigated and remain confidential to the extent permitted by law.  To help us investigate please include a detailed description of the activity and include:

•Provider/Member/Employee name and number (if you have a number available)

•Date of activity or incident

•As much detail about your concern as possible and any relevant information you have.


Reports made via the Compliance Hotline or Website may be done so anonymously.  Please note that reporting via email is not anonymous. 

The Compliance Hotline and Website are administered by EthicsPoint. Please click the link for Frequently Asked Questions to learn more about EthicsPoint. 


Additional Reporting Options:

You may report any potential fraud, waste, or abuse activities directly to the State of Ohio using one of the following options:
Ohio Department of Medicaid  
Phone: (614) 466-0722 or toll free 1-800-324-8680
Website: Reporting Suspected Medicaid Fraud | Medicaid (ohio.gov)

Ohio Medicaid Fraud Control Unit (MFCU)
Fax: 1-877-527-1305
Website:  Report Medicaid Fraud - Ohio Attorney General Dave Yost

You may report any potential fraud, waste, or abuse activities directly to the Federal Government

U.S. Department of Health and Human Services, Office of the Inspector General
Toll Free 1-(800) 447-8477
Website: https://forms.oig.hhs.gov/hotlineoperations/report-fraud-form.aspx

Gainwell is committed to protecting the integrity of the Ohio Medicaid Program.  Medicaid fraud, waste, and abuse (FWA) negatively impacts our members, providers, and community.  Gainwell has invested in a comprehensive program to prevent, detect, and report any potential fraud, waste, or abuse activities.  You can help us by reporting any suspicious activity and we will investigate each report to ensure the Ohio Medicaid Program is protected .

Understanding FWA is key to prevention and detection.  You will find the definitions and examples below.

Fraud
An intentional deception, false statement, or misrepresentation made by a person with the knowledge that the deception, false statement, or misrepresentation could result in some unauthorized benefit to oneself or another person.  It includes any act that constitutes fraud under applicable federal or state law. To be considered fraud the act must demonstrate that a person or entity knowingly submitted, or caused to be submitted, false claims or misrepresentations of fact to obtain a government funded health care payment for which no entitlement would otherwise exist.

Examples of Medicaid Fraud:
 

·Intentionally billing for unnecessary medical services or items 

·Intentionally billing for services or items not provided 

·Unbundling: billing for multiple codes for a group of procedures that are covered in a single global billing code 

·Upcoding: billing for services at a higher level of complexity than provided 

·Card sharing: knowingly treating and claiming reimbursement for someone other than the eligible beneficiary. Member sharing their Medicaid ID card with someone else so they can obtain medical services. 

·Collusion: knowingly collaborating with beneficiaries to file false claims for reimbursement.  Members helping their doctors file claims by having tests done you do not need. 

·Drug Diversion: writing unnecessary prescriptions or altering prescriptions to obtain drugs for personal use or to sell them.  Member altering a doctor's prescription, going to multiple doctors to get more of the same drug, or selling their drugs to others. 

·Kickbacks: offering, soliciting, or paying for beneficiary referrals for medical services or items.  Members accepting payment from their doctor for referring other beneficiaries for medical services. 

·Multiple cards: knowingly accepting multiple Medicaid ID cards from a beneficiary to claim reimbursement.  Members altering or duplicating their Medicaid ID card and using it or selling it for someone else to use. 

·Program Eligibility: Knowingly billing for an ineligible beneficiary. Member providing incorrect information to qualify for Medicaid. 


Waste

Practices that directly, or indirectly result in unnecessary costs such as overusing services. Waste is generally not considered to be caused by criminally negligent actions but rather by the misuse of resources. 

Examples of Medicaid Waste

·Conducting excessive office visits or writing excessive prescriptions 

·Prescribing more medications than necessary for treating a specific condition 

·Ordering excessive laboratory tests 

Abuse

Abuse includes practices that are inconsistent with professional standards of care; medical necessity; or fiscal, business, or medical practices; and that constitute an over utilization of Medicaid covered services and result in an unnecessary cost to the Medicaid program.  These can be actions that may directly or indirectly result in unnecessary costs.  Abuse involves paying for items or services when there is no legal entitlement to that payments, and the provider has not knowingly or intentionally misrepresented facts to obtain payment.

Examples of Medicaid Abuse

·Unknowingly billing for unnecessary medical services  

·Unknowingly billing for brand name drugs when generics are dispensed  

·Unknowingly excessively charging for services or supplies  

·Unknowingly misusing codes on a claim such as upcoding or unbundling codes  ​



Compliance Hotline / EthicsPoint FAQ

Do you suspect Fraud, Waste, or Abuse?

As Ohio's Medicaid Pharmacy Benefit Manager, Gainwell is committed to the prevention and detection of fraud, waste and abuse.
Medicaid can be misused by prescribers, pharmacies, members, contractors, or others. The information contained within this FAQ is intended to help guide you in our process for reporting suspected fraud, waste, and abuse.

What is Ethics Point?
EthicsPoint is a comprehensive and confidential reporting tool created by NAVEX that enables Gainwell and the Ohio Department of Medicaid to work together to address reports of suspicious or irregular actions by a pharmacy, prescriber or beneficiary.

Who is responsible for identifying fraud, waste, and abuse?
Anyone who participates in the Ohio Medicaid Program. This includes but is not limited to:
• Members/beneficiaries
• Prescribers and Pharmacies
• Contractors
• Managed Care Organizations
• Pharmacy Benefit Managers

What is fraud, waste & abuse?
Fraud is the intentional deception, false statement, or misrepresentation made by a person with knowledge that the deception, false statement, or misrepresentation could result in some unauthorized benefit to oneself or another person. It includes any act that constitutes fraud under applicable Federal or State law. Waste and abuse are practices that are inconsistent with professional standards of care; medical necessity; fiscal business, or medical practices; and that constitute an over utilization of Medicaid covered services and result in an unnecessary cost to the Medicaid program.
Examples of Prescriber Fraud Waste and Abuse:
• Billing for services, procedures, prescriptions, and/or supplies that were not provided or rendered
• Intentionally billing for services or items not provided
• Upcoding: billing for services at a higher level of complexity than provided
• Purchasing drugs from outside the U.S.
• Prescribing high quantities of controlled substances without medical necessity
• Prescribing drugs, equipment, or services that are not medically necessary

Examples of Member Fraud Waste and Abuse:
• Sharing a member ID card
• Selling prescribed medications
• Seeking controlled substances from multiple prescribers or pharmacies
• Altering or forging prescription forms
• Adding ineligible people to beneficiary plan
• Falsification of information to obtain benefits such as on enrollment forms or medical documentation

Examples of Pharmacy Fraud Waste and Abuse
• Submitting claims for a more expensive brand name drug when generic drug is available
• Not dispensing prescriptions as written. Such as dispensing less than quantity prescribed without notification to the member or provider.
• Billing for prescriptions that were not filled or picked up by the member
• Dispensing expired, diluted, altered, or illegal drugs

Can I report Gainwell of suspected of fraud, waste, and abuse or other unethical or inappropriate behavior (as Ohio's Medicaid Pharmacy Benefit Manager)?

Yes. Gainwell is committed to our strong values of responsibility and integrity. Gainwell wants you to feel comfortable raising concerns of potential fraud, waste, and abuse. Additionally, Gainwell encourages reporting of concerns of potential violations of law, policy, and other misconduct.

Can I report suspected fraud, waste, and abuse directly to the State or Federal government?

Yes. Suspected cases of fraud, waste, and abuse may also be reported to the applicable regulatory State or Federal agency.

Can I report anonymously?
Yes. Please remember to provide as many details as possible regarding your concern and a clear description of what you believe has happened. The information you provide is important and Gainwell is unable to follow up with an anonymous source for details or clarification, so Gainwell asks that you provide as much information as possible to perform a thorough investigation of your concern.

Where do these reports go and who can access them?
Reports are entered directly onto NAVEX's EthicsPoint secure server. NAVEX makes these reports available only to specific team members within Gainwell's Fraud, Waste, and Abuse Department, who will only provide these reports to the Ohio Medicaid Program Integrity Unit if fraud is identified. Your report will be kept confidential as provided by applicable Federal and State laws. ​


The following resources and policies should be place on this page.

Code Of Conduct​

Gainwell OH SPBM Fraud Waste and Abuse Policy

EthicsPoint FAQ​