Ohio OH

Ohio Single Pharmacy Benefit Manager (SPBM, operated by Gainwell) was established 2022 to centralize all Medicaid drug PA across the 5 OH MCOs. No OH Medicaid MCO processes drug PA. This is structurally distinct from optional PBM-per-MCO models — OH is one of two states (with CA) that fully removed drug PA from the MCO contract.

Ohio (ODM) expresses PA by PAYER-CHANNEL x PLACE-OF-SERVICE, not a single master grid. The provider PA landing (medicaid.ohio.gov/.../prior-authorization-requirements) is a ROUTING HUB: it splits to (1) ODM-published FFS code lists, (2) per-MCO PA pages for the 7 Next Gen MCOs (managed-care medical), (3) SPBM/Gainwell for ALL pharmacy (unified statewide carve), (4) OhioRISE/Aetna for youth complex BH, (5) MyCare Ohio duals. FFS criteria are ODM-published as discrete PDFs: master PA Assignment Codes (3.3MB), Non-Institutional PA requirements, ASC PA codes, and two Inpatient lists (normally-covered-but-require-PA vs normally-non-covered-require-PA). Underlying clinical criteria are codified in OAC Title 5160. URL DECAY: state_meta primary_source_urls for pa_landing, pa_codes (incl. the prior 'healed' wps/wcm repin), and ohiorise all 404 on HEAD/GET; the live canonical host is dam.assets.ohio.gov (Cloudinary-backed DAM). Migration signal, not silently patched. SPBM site is a JS SPA (Gainwell portal) — pharmacy clinical criteria/UPDL are app-gated, not statically harvestable. Gathered 9 authoritative ODM FFS PA criteria + channel-routing PDFs to Corsair.

Last award: 2021-04-09. Next due: unverified. Contracts extended through: unverified (renewal option years; no public re-procurement notice).

status=partial

Current + prior fiscal agents. Tracks ACS-Inc → Conduent/Gainwell transitions so we know when *.acs-inc / *.conduent / *.xerox subdomains die.

# OH — learned PA profile (local Qwen synthesis, 2026-05-28) Synth note: map=qwen2.5:7b / reduce=qwen2.5-coder:32b, 5 docs. See [[state_shape_OH]]. Correction pass: OH IS one of the six WISeR-model states (AZ/NJ/OH/OK/TX/WA), so the WISeR mention is KEPT — but the model's expansion was WRONG. WISeR = CMS's "Wasteful and Inappropriate Service Reduction" Medicare PA model (a Medicare demonstration testing prior-authorization on traditional Medicare in these six states, live Jan 5 2026), NOT a Medicaid "drug benefit transparency" program. The model conflated WISeR with Ohio's Medicaid SPBM. Corrected below. ## 1. How OH requires PA Ohio's Medicaid program requires prior authorization (PA) for various services and drugs to ensure treatments are medically necessary and cost-effective. The requirements vary by service category and place of service. For instance, non-preferred drugs require PA with step therapy, meaning providers must show medical necessity or inadequate response to preferred drugs before obtaining approval. Provider-administered pharmaceuticals also necessitate prior authorization, as do certain vision services (lenses and frames), spinal manipulation, imaging sessions, skilled therapy visits exceeding thirty per benefit year, and most durable medical equipment. ## 2. How OH publishes and reports PA Ohio's Medicaid program publishes its PA requirements through the Ohio Department of Medicaid (ODM) website and monthly bulletins. ODM maintains a routing hub that directs providers to specific PA code lists for fee-for-service (FFS) services and per-MCO PA pages for managed-care medical services. A centralized portal is partially functional but not fully integrated across all service categories. Per source documents, the state's annual report on prior authorization provides aggregate data only (covering FFS and MCOs), without per-service approval rates or appeals data. The 2025 PA report indicates approval rates of 83% (standard) and 98% (expedited), which raises questions about the depth and accuracy of the reported data. ## 3. OH's CMS-0057-F and PA-reform compliance posture Per source documents, Ohio submitted its CMS-0057-F report outlining the state's PA policies and procedures. Ohio uses a carve-out strategy directing pharmacy benefits to a single statewide Pharmacy Benefit Manager (SPBM) operated by Gainwell since 2022 — a centralized model distinct from optional PBM-per-MCO models. Separately, **Ohio is one of six states in CMS's WISeR ("Wasteful and Inappropriate Service Reduction") model** — a Medicare prior-authorization demonstration (live Jan 5, 2026; states AZ/NJ/OH/OK/TX/WA). WISeR is a Medicare-side initiative and is distinct from Ohio's Medicaid SPBM; the local model incorrectly described WISeR as a Medicaid drug-benefit-transparency program, which is corrected here. The Medicaid annual PA report lacks detailed granularity. ## 4. How OH runs its own program Ohio's Medicaid program is structured around a managed-care model with multiple MCOs and a centralized FFS system. The state uses a routing hub on the ODM website to direct providers to specific PA requirements by service category and place of service. The Ohio Single Pharmacy Benefit Manager (SPBM), operated by Gainwell, handles all drug prior authorization across the MCOs, ensuring consistency in drug coverage policies. The program includes several carve-outs: - **Pharmacy Carve-out:** Directed to a single statewide PBM (SPBM). - **Behavioral Health (BH):** Managed through specialized arrangements (per source documents, pediatric services via OhioRISE). - **Long-Term Services and Supports (LTSS):** Handled by specialized dual plans. Per source documents, ODM implemented a moratorium on enrolling new Home Health and Hospice providers from May 14, 2026, through November 14, 2026. ## 5. Patterns, what's notable, and what's missing/uncertain ### Notable Patterns: - **Centralized Pharmacy PA:** Ohio has a single statewide PBM (SPBM) for all drug prior authorization. - **WISeR-model state:** OH is one of six states in CMS's Medicare WISeR PA demonstration (correct expansion: Wasteful and Inappropriate Service Reduction). - **High Approval Rates:** Reported Medicaid approval rates (83% standard / 98% expedited) raise questions about reporting depth/accuracy. - **Carve-outs:** Pharmacy, behavioral health, and LTSS carve-outs indicate a structured approach. ### Missing/Uncertain: - **Detailed Reporting:** The annual Medicaid PA report lacks per-service-category breakdowns and appeals data. - **Transparency in Data:** High approval rates warrant further investigation. - **Foster Care Program Details:** Unspecified in the sources. - **Gold Card Law:** Status unspecified.