ODM (Ohio Department of Medicaid) Director Maureen Corcoran announced a proposed 5.7% increase in the Professional Dispensing Fee (PDF) for the SPBM (Single PBM) pharmacy program as part of the biennial state budget. The percentage as proposed would be applied to all three PDF tiers. NACDS has been advocating for an increase since the September announcement of the PDFs for the SPBM The budget also includes an opportunity for pharmacies to enhance PDFs through a outcomes-based incentive payment. No further details are available upon this writing, but NACDS expects to have them soon.

For more information, contact NACDS’ Jill McCormack at 717-592-8977.

ODM (Ohio Department of Medicaid) posted Myers & Stauffer’s 2022 Fee-For-Service Pharmacy Cost of Dispensing Survey report.  NACDS is currently analyzing the report that found that the cost to dispense increased since 2020 but that increase was mostly prevalent among smaller pharmacies. Survey results included a weighted mean of $9.46 and a weighted median of $8.44 as the cost to dispense for non-specialty providers.

Also in Ohio, ODM Director Maureen Corcoran testified about the proposed biennial budget proposal, confirming that the proposal includes funding for a “modest” pharmacy Professional Dispensing Fee (PDF) increase. NACDS has been advocating for an increase since the September announcement of the PDFs for the SPBM (Single PBM). No details are yet available, but NACDS expects to update members very soon.

Finally, in Ohio, ODM and Gainwell (SPBM) are continuing to re-implement prior authorizations (PA) requirements in stages by specific drug classes. The reimplementation only applies to new, initial authorizations. Phase 3 begins on February 14 for these specific classes:  

• Age Restricted Medications (denoted with “AR” on the UPDL (Unified Preferred Drug List)) 
• Benzodiazepines 
• Central Nervous System (CNS) Agents: Skeletal Muscle Relaxants, Non-Benzodiazepine
• Endocrine Agents: Diabetes- Insulin 
• Endocrine Agents: Diabetes- Non-Insulin 

Members can reference the Unified Preferred Drug List on the SPBM portal to see products that require a PA. Additional PAs will be reimplemented during the first quarter of 2023.  

For more information, contact NACDS’ Jill McCormack at 717-592-8977.

The next payment for the Supplemental (managed care) dispensing fee (as pharmacy commonly refer to it) is scheduled to be paid to pharmacies between February 1-15. This is the first payment of the fee for 2023 and since the October 1 implementation of the SPBM. Under the SPBM, the payments will run as a special financial cycle and will appear on the non-Claim 835. You can identify these payments on your Remittance Advice by the reason code of 9638 – “QtrSuppDispFee.” For more information, please see the FAQ ODM was issued this week. The supplemental fee expires in June 2023, as it was meant to be a stopgap to assist pharmacies while the SPBM system was being developed. 

Also in Ohio, NACDS submitted a comment letter to the Common Sense Initiative (CSI) regarding the Board of Pharmacy’s proposed rule that would allow pharmacy technicians to administer vaccines. The letter expresses pharmacy’s strong support for the bill but asks that the CSI recommend that the Board remove the ratio for technician vaccinators and align the training requirement hours with the PREP Act.  

Finally in Ohio, the Department of Medicaid posted Myers & Stauffer’s 2022 Pharmacy Cost of Dispensing Survey report. NACDS is currently analyzing the report that found that the cost to dispense increased since 2022. They reported a weighted mean of $9.46 and a weighted median of $8.44 as the cost to dispense for non-specialty providers. 

For more information, contact NACDS’ Jill McCormack at 717-592-8977.

The Board of Pharmacy (BOP) released another draft rule for stakeholder feedback from the Pharmacy Workforce Advisory Committee. This rule would establish mandatory breaks for pharmacy personnel. Members may submit comments to the BOP by January 20, 2023. Please note that the document also has guidance related to the current law around protections against employee violation reports to the Board.

For more information, contact NACDS’ Jill McCormack at 717-592-8977.

The SPBM (Single Pharmacy Benefit Manager), Gainwell Technologies, sent a communication to pharmacies this week detailing claim recoupments that are planned in the next few weeks to compensate for overpayments in the first three weeks of the migration to the new Medicaid managed care pharmacy system.

For more information, contact NACDS’ Jill McCormack at 717-592-8977.

This week, ODM (Ohio Department of Medicaid) (Ohio Department of Medicaid) reversed its policy that required provider participation in the Vaccines for Children (VFC) program under the SPBM (Single Pharmacy Benefit Manager), Gainwell. To increase access to pediatric vaccines, Gainwell announced they will now cover pediatric vaccine claims by non-VFC providers, reimbursing product costs and an administration fee. NACDS worked jointly with the Ohio Council of Retail Merchants and members to advocate for this policy with both ODM and the Governor’s office.

For more information, contact NACDS’ Jill McCormack at 717-592-8977.

This week, Ohio Medicaid announced the payment schedule for the Supplemental Managed Care Dispensing Fee and that the fee has been increased due to the compressed schedule of payments. The payment schedule is:

Payment 5 – Between November 1 – 15, 2022 (July – Sept 2022 claims)

Payment 6 – Between February 1 – 15, 2023 (Oct – Dec 2022 claims)

Payment 7 – Between May 1 – 15, 2023 (Jan – March 2023 claims)

Payment 8 – No later than August 15, 2023 (April – June 2023 claims)

Note that the November payment will be issued by the Medicaid MCOs (Managed Care Organizations) and, as in the past, will be included in your weekly claim payments. However, the balance of the payments will come from Gainwell, the SPBM (Single Pharmacy Benefit Manager), as a separate payment. The FAQ document includes more detail.

Also in Ohio, Medicaid has prepared a toolkit for providers to prepare for the expiration of the federal Public Health Emergency (PHE). The materials are focused on the “unwinding” patient eligibility that will result at the end of the PHE.

For more information, contact NACDS’ Jill McCormack at 717-592-8977.

As you are aware, Ohio Medicaid (ODM) implemented the Single PBM, Gainwell, at Midnight on October 1. NACDS has been working with members, ODM and Gainwell daily to provide solutions as they work through technical issues causing denials, many of which have since been resolved or temporarily patched over. To report any major system issues, please use the dedicated email that Gainwell/ODM is monitoring in real-time. If you need NACDS’ assistance to emphasize significant issues, please contact Jill McCormack.

For more information, contact NACDS’ Jill McCormack at 717-592-8977.

NACDS reminds members that at midnight on Saturday Oct. 1 the state’s SPBM (Single Pharmacy Benefit Manager), Gainwell, will being processing managed care pharmacy claims. Beginning October 1, pharmacy benefits for managed Medicaid members will be covered by the Single Pharmacy Benefit Manager (SPBM), Gainwell Technologies. Gainwell’s provider manual, also known as the pharmacy reference guide, is the primary resource guide providing key information to pharmacy providers, pharmacy support staff, and prescribers. The provider manual includes information related to pharmacy claims submission, reimbursement rates, pharmacy network requirements, the specialty pharmacy program, claims processing, utilization management, and prior authorization. More information can be accessed at ODM’s Next Generation website or the Gainwell Ohio Pharmacy website. 

Also in Ohio, the Board of Pharmacy has posted the agenda for Public Hearing 10.26.22 and a document regarding the Pathway to Pharmacy Technician Registration for Veterans 

For more information, contact NACDS’ Jill McCormack at 717-592-8977.