Pharmacy

Effective October 2022, Gainwell Technologies is the Single Pharmacy Benefit Manager (SPBM) for the Ohio Department of Medicaid (ODM) pharmacy program. All CareSource members receive pharmacy benefits through the SPBM.

CareSource continues to provide coverage for provider administered drugs under the medical benefit with the exception of provider administered drugs for members with coverage under the OhioRISE program.

Single Pharmacy Benefit Manager Pharmacy Benefits

Gainwell Technologies covers all Medicaid-covered, medically necessary prescriptions, certain over the counter (OTC) medications, vaccines, and select durable medical equipment. Gainwell Technologies uses the Unified Preferred Drug List (UPDL), which is a list of drugs covered under the plan. The Ohio Department of Medicaid maintains this list and updates regularly.

Visit the Ohio Department of Medicaid pharmacy website to view the most up-to-date UPDL.

For prescriptions and products covered through the SPBM, prior authorization may be required before a claim will be accepted. Refer to the UPDL to determine which drugs need prior authorization. Providers may submit a prior authorization directly to Gainwell Technologies through one of the following methods:

Phone: 833-491-0344 from 8 a.m. to 8 p.m. EST Monday through Friday
Fax:    833-679-5491
Mail:   Gainwell Technologies
           OH SPBM
           P.O. Box 3908
           Dublin, OH 43016-0472

Portal: https://spbm.medicaid.ohio.gov

Visit Gainwell Technologies for additional information.

Provider Administered Drugs

Some drugs may require prior authorization before they will be covered. Refer to the Procedure Lookup Tool to determine which drugs need prior authorization.

For all prior authorization decisions (standard or urgent), CareSource provides notice to the provider and member as expeditiously as the member’s health condition requires. Please specify if you believe the request is urgent and requires expedited review.

Prior Authorization requests for medications covered under outpatient Medical Benefit for Medicaid may be submitted electronically through the CareSource Portal or by fax at 888-399-0271.

You may submit requests using the following forms:

• Hyaluronic Acid Injections Prior Authorization Form
• Medical Provider Administered Drugs Prior Authorization Form
• Synagis Prior Authorization Form

Please include the following information when submitting a prior authorization for drugs administered under the medical benefit:

• The drug name
• J-code and National Drug Code (NDC) number
  • Refer to the appropriate pharmacy or medical policy for the most up-to-date J-code and NDC number for the medication you are requesting

• Drug dosing, including the strength and form
• Directions for use (SIG)
• Date(s) of service and duration of treatment requested
• Provider information (for both the ordering and rendering providers including NPI and Tax IDs)
• Supporting clinical documentation and/or chart notes

Claims for specialty medications must include:

• HCPCS Code
• NDC number
• Revenue code 636, if administered in the outpatient setting

Note: Miscellaneous HCPCS Code (i.e. J3490, J3590, J8499) must be billed with an NDC number in order for the claim to pay.

Note: Providers registered with the Ohio Department of Medicaid as a Pharmacy (Provider Type 70) must bill all pharmaceuticals to the SPBM per Ohio Administrative Code 5160-26-13. Claims billed to CareSource for provider administered drugs by a Pharmacy will be denied.

Note: Please verify the CS Provider ID, Tax ID and NPI for the rendering provider before submitting the request. This information must match the claim in order to avoid delays in claims payment.

Provider Administered Drugs Covered by OhioRise

OhioRISE covers medications given to members in the office to treat mental health and substance use disorders. For more information, visit the OhioRise provider website.

Policies

CareSource Pharmacy policies include drug specific and therapy class policies to be used as a guide when determining health care coverage for our members for provider administered drugs.

The policies are written for those drugs that are formulary, non-formulary, non-preferred, preferred with prior authorization or require step therapy. The policy is a tool to be interpreted in conjunction with the member’s specific benefit plan. Access pharmacy policies by selecting Policies from the Quick Links for more information.

Generic Substitution

Generic drugs approved by the Food and Drug Administration (FDA) have the same quality, strength, purity, and stability as brand name drugs. Members and providers can expect the generic to produce the same effect and have the same safety profile as the brand name drug. Generic drugs must be used when available. If a brand name product is requested when a generic equivalent is available, you will need to request a prior authorization and explain why the member cannot use the generic drug.

Quantity Limits

Some drugs have limits on how much can be given to a member at one time. Quantity limits may be based on several factors such as drug makers’ recommended dosing, patient safety, or the Food & Drug Administration (FDA) recommendations.

Step Therapy

Sometimes, CareSource will require a member to try a less expensive drug used to treat the same condition before “stepping up” to a medication that costs more. This is called step therapy. Certain drugs may only be covered if step therapy is met.

Coordinated Services Program (CSP)

CSP is a health and safety program which protects members whose use of services exceeds medical necessity. Use of controlled substances is monitored, and members are assigned designated providers. A designated provider is usually a pharmacy, but may include a single prescriber, or both a single pharmacy or a single prescribers. CSP enrollees must get medications using their designated providers. In the event of an emergency and the member is unable to use the designated provider, call Member Services at toll free at 1-800-488-0134.

If you would like to refer someone to be considered for CSP, please click here and provide the following information:

• Member’s name
• Member’s date of birth
• Member’s CareSource ID number

Drug Safety Recalls

Sometimes, a drug manufacturer or the federal government issues drug recalls. To find out if a drug you have prescribed to a patient is being recalled, please check the listings on the FDA website.