The Pharmacy Benefit for Ohio Medicaid is managed for the UnitedHealthcare Community Plan of Ohio members by Gainwell Technologies on behalf of the Ohio Department of Medicaid.
Find pharmacy information related to prescription drugs including prescription drug lists, step therapy, quantity limits and prior authorization requirements for Community Plan care providers at the Gainwell website.
In response to the U.S. opioid epidemic, UnitedHealthcare has developed programs to help our members receive the care and treatment they need safely and effectively.
We’ve also established measures based on the Centers for Disease Control and Prevention’s (CDC) opioid treatment guidelines to help prevent overuse of short-acting and long-acting opioid medications.
Resources
See below for current pharmacy clinical guidelines and updates.
Visit the Policies and Clinical Guidelines page for more information.
Gainwell Technologies is the Single Pharmacy Benefit Manager (SPBM) for all UnitedHealthcare Community Plan of Ohio members.
Specialty medications can be covered under the pharmacy benefit, the medical benefit or both benefits, depending on the benefit structure for the member’s coverage.
Pharmacy benefit medications are typically self-administered by the patient or a caregiver, after filling the prescription through a pharmacy. These medications are labeled for self-administration by the Food and Drug Administration but may require some instruction to the patient or caregiver.
Typically, medications administered orally, topically or through subcutaneous injection by the patient or a caregiver after receiving instruction are covered under the pharmacy benefit.
Medical benefit medications are typically administered by a health care professional and monitored by a health care professional. The medication is administered in a physician office, at home, in an ambulatory infusion suite or in an outpatient facility. These medications can be administered by infusion, injection or intramuscularly with the help of an infusion nurse.
Specialty Pharmacy medications can be shipped from a specialty pharmacy directly to a health care setting (i.e., sourced) or a provider may purchase them directly using their standard distribution process (i.e., buy and bill). If the drugs are administered at home, they may be shipped from a specialty pharmacy directly to the member’s home.
Coverage of a requested medication depends on the member’s Medicaid coverage as determined by the State Medicaid agency, and the availability of a specific drug from a network specialty pharmacy may vary.
Medications obtained through a specialty pharmacy will be directly billed to the member’s health plan.
To locate a contracted specialty pharmacy, download the list: Provider Vendor Assistance List - Specialty Pharmacy.
The Unified Preferred Drug List (UPDL) is a list of prescription drugs considered coverable by Gainwell Technologies, the Single Pharmacy Benefit Manager for all UnitedHealthcare Community Plan of Ohio members.
For questions about finding a pharmacy in the network, medications or prior authorization, contact Gainwell at spbm.medicaid.ohio.gov or contact by phone at 1-844-539-2057