On October 1, 2022, the SPBM will begin providing pharmacy services for Medicaid covered individuals across all managed care plans and members. The goal of the SPBM is to improve management and administration of the pharmacy benefits for Medicaid members with a managed care plan to ensure transparency and accountability and improve administrative processes for providers. This new system includes checks and balances that prevent conflicts of interest related to medication requirements and coverage. When launched, providers will use the PNM to access the SPBM with any prior authorization requests and those will be managed by the SPBM.

The Ohio Council met with ODM leadership and engaged with several stakeholders to submit comments related to proposed rule changes for the Medicaid pharmacy benefit. The changes would have impacted behavioral health organization’s access to long acting injectables (LAI) and medication assisted treatment (MAT) and required organizations to buy and bill these medications through the medical benefit as opposed to the pharmacy benefit. This would have represented a significant cost shift to behavioral health providers. Our advocacy efforts were successful and resulted in changes to the proposed rule to allow the current option for provider-administered medications to be covered by the Medicaid pharmacy benefit to remain intact.

The ODM draft rule and guidance document outline the pharmacy process flow and payment process. Operationally, this means the pharmacy will bill the SPBM for only the pharmaceutical dispensed. The PT 84/95 that is administering the drug will bill the MCO for the medication administration charge on a medical claim. The Ohio Council clarified with ODM that medications on the Medicaid Unified Preferred Drug List (UPDL) , including those that are prescriber administered, will be billed through any in-network SPBMpharmacy (operated by Gainwell Technologies). Providers will not have to use the managed care plan’s specialty pharmacy network, unless the medication is identified as a specialty drug. Gainwell is currently working on contracting with all ODM enrolled pharmacy providers.