It’s important to Buckeye Health Plan that our members receive drug therapy that is appropriate, high quality and cost effective. We work hard to ensure you have access to safe and effective medications that are medically proven to help you get healthy and stay healthy.
Single Pharmacy Benefit Manager (SPBM)
In 2019, the Ohio Legislature directed ODM to make a shift in the Medicaid pharmacy program and select and contract with a single pharmacy benefit manager (PBM). ODM’s goals for the single pharmacy benefit manager (SPBM) are to improve management and administration of pharmacy benefits for managed care recipients. Through SPBM, ODM will gain increased financial accountability and ensure alignment with our clinical and policy goals, while also improving transparency. ODM selected Gainwell Technologies as the SPBM for Ohio Medicaid.
On October 1, 2022, the SPBM will begin providing pharmacy services across all managed care plans and members. Until the SPBM goes live on October 1, 2022, there is no change to the current process for submitting pharmacy claims or pharmacy prior authorizations. Through SPBM, pharmacists and prescribers will see benefits from streamlining and consolidation of processes currently provided by multiple, individually contracted PBMs. The SPBM will be responsible for maintaining the Unified Preferred Drug List (UPDL), and will also include implementation of a single set of clinical and prior authorization policies and claims process, and provide a standard point of contact, reducing the administrative burden on providers.
For Medicaid managed care members, the SPBM will provide more choice in selecting their pharmacy due to fewer out-of-network restrictions. In addition, members will no longer need to consider pharmacy benefits as a decision-making factor when selecting a managed care plan. The SPBM can also incentivize member-valued services and benefits like home delivery, 90-day refills, and adherence programs. Members may also refer to the Gainwell Technologies portal for more information, or call Gainwell member services at 1-833-491-0344 (TTY 1-833-655-2437).
Unified Preferred Drug List (PDL)
The Preferred Drug List (PDL) is the list of drugs covered by Buckeye Health Plan. The Ohio Department of Medicaid, in partnership with the Medicaid managed care plans (MCPs), has created a unified preferred drug list (UPDL). All Ohio Medicaid MCPs will prefer the same medications and use the same prior authorization criteria for the majority of drug categories. This unified list, of drugs will help you know which drugs are covered with or without prior approval. Prior approval is also called prior authorization.
You can find a copy of the UPDL in the following locations:
- Logging in to your Gainwell Member Portal on Gainwell's website
- The Ohio Department of Medicaid pharmacy website
- A paper copy can be requested by calling Gainwell member services at 1-833-491-0344 (TTY 1-833-655-2437)
If a prescription drug you take is no longer preferred, you will be notified by your doctor, MCP or pharmacy. You may need to change your current drug(s) or ask your prescriber to submit a prior authorization request to stay on your current drug(s). If you receive a letter in the mail from Buckeye Health Plan, make sure to review the letter carefully. You should discuss this information with your prescriber at your next visit or call your prescriber at your earliest convenience. However, if you go to the pharmacy to refill your prescription before your next visit, you might be told that your drug requires prior authorization. We will work with your prescriber to cover a drug that meets your needs. You will not lose drug coverage. Please note that you will also continue to use the same Medicaid ID.
If you have questions or problems with your prescription, call Buckeye member services by dialing the toll-free number 1-866-246-4358 on your Medicaid ID card.
Through the Unified Preferred Drug List (UPDL), Buckeye Health Plan covers certain prescription drugs and over-the-counter drugs when prescribed by a Buckeye Health Plan provider. The pharmacy program does not cover all drugs. Some require prior authorization. Some drugs have limitations on age, dosage or maximum quantities.
The Unified Preferred Drug List (UPDL) is the list of drugs covered by Buckeye Health Plan. Buckeye Health Plan works with the Ohio Department of Medicaid (ODM), providers and pharmacists to ensure that medications used to treat a variety of conditions and diseases are covered. The UPDL applies to drugs you receive at retail pharmacies. The UPDL is continually evaluated by ODM’s Pharmacy and Therapeutics Committee to promote the appropriate and cost-effective use of medications.