Members

For more information or to request member outreach, please call Gateway’s Preventive Health Department at 1-800-642-3550, press option 4. You can also fax the Member Outreach Form to the fax number listed on the Form.

The Enrollment Process

Gateway is only offered to Medical Assistance recipients within Gateway’s service area. Gateway serves Medical Assistance recipients as a voluntary alternative to the traditional fee-for-service program and as an option in the HealthChoices mandatory program.

The enrollment process for the voluntary counties begins with a Gateway Marketing Representative determining that an individual is a Medical Assistance recipient. The representative explains Gateway’s operations, and policies and procedures in detail. If the recipient is interested, they complete and sign an application to enroll in Gateway. When completing the enrollment application, the potential member is required to select a primary care practitioner from a list of participating practitioners. Gateway electronically submits all applications to the Department of Public Welfare for validation. If the recipient is Medical Assistance eligible, the Department of Public Welfare will assign an effective date with Gateway that is two (2) to six (6) weeks in the future.

Under the HealthChoices Program(s), an Enrollment Specialist assists the recipient in selecting a Physical Health Managed Care Organization (PH-MCO) that meets their needs. The Enrollment Specialists are employed by the Department of Public Welfare’s Independent Enrollment Assistance Program (IEAP) contractor, and they explain the benefits offered by Gateway and the other PH-MCO options. Potential members are encouraged to select a primary care practitioner from a list of participating practitioners. The IEAP contractor electronically submits all applications to the Department of Public Welfare to validate. The Department of Public Welfare then electronically notifies the IEAP contractor and Gateway that a recipient will be enrolled in Gateway.

Medical Assistance recipients approved by the Department of Public Welfare from either the voluntary or HealthChoices programs are added to Gateway’s Information System, with the effective date assigned by the Department of Public Welfare. Newly enrolled members receive a new Member Handbook and a Gateway Identification Card. (see sample Gateway ID Card below)

Medical Assistance ACCESS Cards
The Department of Public Welfare issues a Pennsylvania ACCESS card to all eligible Medical Assistance recipients, including those recipients that choose to join Gateway. All Gateway members will have both a Department or Public Welfare ACCESS card and a Gateway identification card. If a patient presents an ACCESS card, the member’s eligibility can be verified through Gateway’s Digital Voice Assistant (DIVA) at 1-800-642-3515, or the Department of Public Welfare Eligibility Verification System (EVS). Practitioners must participate with the Medical Assistance Program in order to use the EVS.

To access the Department of Public Welfare EVS, call 1-800-766-5EVS (5387). Please have your 13-digit Master Provider Index (MPI) Number and the member’s Recipient Number from the member’s ACCESS card available when you call. Since important information is provided throughout the verification process, please listen to the entire message. If the recipient is covered by a managed care plan, such as Gateway, their eligibility with the plan is indicated immediately following the member’s demographic information (name, date of birth, etc.).

The Point of Service (POS) swipe-box provided by the Department of Public Welfare confirms all of the information provided through the EVS phone system, and provides printed verification for your records.

The following information is available from the EVS 1-800 number/POS device/PC Software:

Managed Care Information	If the recipient is enrolled in a Managed Care Organization (MCO), EVS will provide the name and telephone number of the MCO, as well as the recipient’s primary care practitioner name and the telephone number. The system will inform you if the recipient has managed care coverage extending beyond the period of his/her Medical Assistance coverage.
Recipient Restriction Information	If the recipient has been restricted to certain practitioners, EVS alerts the practitioner to whom the recipient is restricted.
ACCESS Card Information	When an invalid card number is entered, EVS will indicate so by returning a message that the recipient is not eligible.

Determining Eligibility Through Gateway

Because of frequent changes in a member’s eligibility, each participating practitioner is responsible for verifying a member’s eligibility with Gateway BEFORE providing services. Verifying a member’s eligibility will ensure proper reimbursement for services. To verify a member’s eligibility, the following actions are available to all practitioners:

Gateway Identification Card

The card itself does NOT guarantee that a person is currently enrolled in Gateway. Members are NOT required to return their identification cards when they are no longer eligible for Gateway.

The Gateway DIVA System (1-800-642-3515) is available 24 hours a day, seven days a week. To verify member eligibility at each visit, practitioners follow a few simple steps, which are listed below:

TO VERIFY MEMBER ELIGIBILITY

Press 1 to verify eligibility

Member Identification Number?

Press 1 to verify eligibility using the patient’s social security number, when prompted enter the patient’s 9-digit social security number, then press the # key

Press 2 to verify eligibility using the patient’s Gateway member identification number, when prompted enter the patient’s 10-digit Gateway identification number, then press the # key
Press 4 to verify eligibility using the patient’s Medical Assistance recipient identification number, when prompted enter the patient’s Medical Assistance recipient identification number, then press the 3 key

Press 0 to speak to a Provider Services RepresentativePress 9 to repeat the menu

Verification of Date?

Press 1 to verify whether the patient is eligible TODAY
Press 2 to verify whether the patient is eligible on a specific date (enter date)
Press 9 to listen to the instructions again
Press 0 to speak to a Provider Services Representative

Additional Instructions:

Press 1 to receive additional information about the patient/member
Press 2 to received the patient’s primary care practitioner name and telephone number
Press 3 to fax information regarding the patient whose eligibility is being verified
Press 4 to verify eligibility for another patient/member
Press 5 to exit
Press 0 to speak to a Provider Services Representative

ACCESS Cards

Showing a Medical Assistance ACCESS card does not indicate membership in Gateway.
Use the swipe-box or call EVS at 1-800-766-5EVS (5387)

Primary Care Practitioner’s Role in Determining Eligibility

Primary care practitioners verify eligibility by consulting their panel listing in order to confirm that the member is a part of the practitioner’s panel. The panel list is distributed on or about the first of every month. The primary care practitioner should check the panel list each time a member is seen in the office. If a member’s name is on the panel list, the member is eligible with Gateway for that month.

If members insist they are effective, but do not appear on the panel list, the practitioner should call the Gateway Provider Servicing Department at 1-800-392-1145 for help in determining eligibility.

Addition of Newborns

When a member selects Gateway, the member’s effective date is usually the first or the 15^th of the month. However, when the member is a newborn, the member may be added at any time during the month. Because information on newborns is reported to Gateway retroactively, newborns will show up as a retrospective addition to the primary care practitioner’s next monthly panel listing. Newborns will be effective on their date of birth or the date the newborn was added to the member’s grant.

Member Benefit Packages and Copayments

Changes made in the Pennsylvania Medical Assistance program through the Governor's 2005/2006 budget permitted Medicaid Managed Care Plans to implement the copayments and service limits in effect in the Medicaid FFS program. Gateway Health Plan^® has implemented copayments and service limits for those members covered under the Adult General Assistance (Adult GA) and Adult Medical Assistance (Adult MA) benefit categories effective January 15, 2006.

Gateway members that are age 18 or older have copayments and some members age 21 or older have service limits and copayments. Copayments do not apply to any member who is pregnant (through the postpartum period beginning on the last day of the pregnancy and extending through the end of the month in which the 60day period following termination of the pregnancy ends) or in a nursing home. Members cannot be denied a service if they are unable to pay their copayment.

Members are responsible up to a maximum of $90 for Adult MA and $180 for Adult GA every six months. Gateway will reimburse the member for any applicable copays based upon claims submission that exceed the maximum from January through June and again from July through December of each year.
The provider is required to submit in field 29 of the CMS1500 form and field 54 of the UB92 form the patient responsibility amount. Gateway's system automatically deducts the copayment from the provider's reimbursement and reflects this in the provider's Remittance Advice. Gateway tracks the applicable copayments on each claim and through a retrospective analysis will identify members that reach the thresholds and issue member reimbursements as necessary.

Exception for Service Limits

Members and practitioners may request an exception for services above the service limits by calling Gateway's Utilization Management Department at 18003921146. All exception requests are reviewed for medical necessity and can be granted if:

The member has a serious chronic illness or other serious health condition and without the additional service their life would be in danger; or
The member has a serious chronic illness or other serious health condition and without the additional service their health will get much worse; or
The member would need more costly services if the exception is not granted; or
The member would have to go into a nursing home or institution if the exception is not granted.
Granting the exception is necessary in order to comply with state regulations.

Any exception request received prior to the service being rendered will get a response within 21 days of the date Gateway received the request. Prospective urgent exception requests will be responded to within 48 hours of the date and time Gateway received the request and requests received after the service has been rendered will be responded to within 30 days of the date that Gateway received the request.

A retrospective request for an exception must be submitted no later than sixty (60) days from the date Gateway rejects the claim because the service is over the benefit limit. Retrospective exception requests made after sixty (60) days from the claim rejection date will be denied.

Both the recipient and the provider will receive written notice of the approval or denial of the exception request. For prospective exception requests, if the provider or recipient is not notified of the decision within twentyone (21) days of the date the request is received, the exception will be automatically granted. Gateway denials of requests for exception are subject to the right of appeal by the Provider or recipient.

A provider may not hold a Gateway member liable for payment for services rendered in excess of the limits established unless the following conditions are met:

The provider has requested an exception to the limit and Gateway denied the request.
The provider informed the member before the service was rendered that the recipient is liable for payment if the exception is not granted.

Practitioners can verify a member's medical assistance benefit category through the Department of Public Welfare PROMISe Eligibility Verification System (EVS). Once a member's benefit category is verified, practitioners can use the reference table below to determine the applicable copayments and limits based on the members "Physical Health Benefit Package". If you have questions about the information in the reference table, call Gateway's Provider Services Department at 1-800-392-1145.

ADULT MEDICAL ASSISTANCE BENEFIT PACKAGES (1, 2, 4, 8, 10, 13,14)			ADULT GENERAL ASSISTANCE BENEFIT PACKAGES (3 & 5)
BENEFIT	COPAY*	COMMENT	BENEFIT	COPAY*	COMMENT
Brand Name RX	$3.00	Applicable to age 18 and older	Brand Name RX	$3.00	Applicable to age 18 and older
Generic Drug RX	$1.00	Applicable to age 18 and older	Generic Drug RX	$1.00	Applicable to age 18 and older
Inpatient Hospital (General or Rehab)	$3/per day, up to $21/per admission	Applicable to age 18 and older	Inpatient Hospital (General or Rehab)	$6/per day, up to $42/per admission	Applicable to age 18 and older
Hospital Short Procedure Unit (SPU)	$3/per service	Applicable to age 18 and older	Hospital Short Procedure Unit (SPU)	$6/per service	Applicable to age 18 and older
Office Visits (Not applicable to PCPs, OBs, GYNs and OB/GYNs)	$2/per service	Applicable to age 18 and older and Federally Qualified Health Centers (FQHC)	Office Visits (Not applicable to PCPs, OBs, GYNs and OB/GYNs)	$4/per service	Applicable to age 18 and older and Federally Qualified Health Centers (FQHC)
Nuclear Medicine Services	$1/per service	Applicable to age 18 and older and hospital component only	Nuclear Medicine Services	$2/per service	Applicable to age 18 and older and hospital component only
Radiology Services	$1/per service	Applicable to age 18 and older and hospital or physician office	Radiology Services	$2/per service	Applicable to age 18 and older and hospital or physician office
BENEFIT	LIMIT**	COMMENT	BENEFIT	LIMIT**	COMMENT
Chiropractor and Podiatrist Outpatient Visits	18 combined outpatient visit limit/per year	Applicable to age 21 and older	Chiropractor and Podiatrist Outpatient Visits	18 combined outpatient visit limit/per year	Applicable to age 21 and older
Inpatient Medical Rehabilitation	1 inpatient medical rehab admission/per year	Applicable to age 21 and older	Inpatient Medical Rehabilitation	1 inpatient medical rehab admission/per year	Applicable to age 21 and older
			Inpatient Acute Hospital	1 inpatient acute admission/per year	Applicable to age 21 and older; not applicable to emergency admissions or admissions related to pregnancy
			Pharmacy	6 prescriptions or refills/per month	Applicable to age 21 and older

*Copayments do not apply to any member who is pregnant (through the postpartum period beginning on the last day of the pregnancy and extending through the end of the month in which the 60-day period following termination of the pregnancy ends) or in a nursing home. Members covered under the MA Adult benefit category do not have a copayment for the following kinds of drugs:

Drugs, including immunizations, that you get in the doctor's office
Antihypertensive agents
Antidiabetic agents
Anticonvulsants
Cardiovascular preparations
Antipsychotic agents, except those that are also schedule CIV antianxiety agents
Antineoplastic agents
Antiglaucoma drugs
AntiParkinson drugs
Drugs used only to treat HIV/AIDS>

The pharmacy will inform the member of any applicable copay for a prescription. Members cannot be denied a service if they are unable to pay their copay.

**The yearly limits refer to services rendered between January 15, 2006 and June 30, 2006. The yearly limits will start again on July 1 of every year. Providers or members may request an exception to approve services above the yearly limits based on medical necessity.

Benefits

Medical Benefits

Gateway members are eligible for all the benefits covered under the Pennsylvania Medical Assistance Program. Members obtain most of their healthcare services either directly from or upon referral by their primary care practitioner, except for services available on a selfreferral basis, such as family planning services, OB/GYN services, routine dental services, routine vision services, and mental health/substance abuse services. The primary care practitioner is responsible for the coordination of a member's healthcare needs and access to services provided by hospitals, specialty care practitioners, ancillary providers, and other healthcare providers as needed.

Medical Assistance Benefits Package

The Department of Public Welfare has developed fourteen (14) Healthcare Benefit Packages. Each package was determined by dividing the recipient community into specific groups based on common eligibility characteristics. Under Medical Assistance, many benefits vary by the Healthcare Benefit Package of the recipient. A chart identifying the Gateway benefits, which varies by Medical Assistance Healthcare Benefit Package, follows:

Benefit	Under 21 Full Benefit	Over 21 Full Benefit	Over 21 Limited Benefit
Vision	Eye Examinations are a covered benefit. Additional benefits available for services deemed medically necessary under Early Periodic Screening and Diagnostic Testing (EPSDT).	Eye Examinations are a covered benefit.	Eye examinations are a covered benefit.
Dental	Full MA Benefits	Full MA Benefits	Limited Gateway Benefits
Pharmacy	Full Gateway Benefits	Full Gateway Benefits	Limited Gateway Benefits

Medial Assistance Categories

Categorically needy who receive cash and medical assistance:
C = TANF	J = SSI Disabled
D = General Assistance, Chronically Needy	M = SSI Blind
A = SSI Aged	U = TANF

Categorically needy who do not receive cash assistance, but only receive medical assistance:
PC = NMP TANF	PH = Healthy Horizons and Breast/Cervical Cancer
PU = NMP TANF	PAN = NMP Long Term Care
PD = General Assistance, NMP	PAW = NMP Waiver Program
PK = General Assistance, NMP	PW = NMP Waiver Special Group
PS = Healthy Beginnings	PCN = Workers with Disabilities
PA = NMP Aged	PJN = NMP Disabled Long Term Care
PJ = NMP Disabled	PJW = NMP Disabled Waiver
PM = NMP Blind	PMN = NMP for Blind Long Term Care
PI = Workers with Impaired Disabilities	PMW = NMP for Blind Waiver

Medically needy who do not receive cash assistance and do not qualify as categorically needy:
TC = TANF, Medically Needy Only	TM = SSI Blind
TU = TANF, Medically Needy Only	TJW = MNO Aged Waiver
TA = Medically Needy Only	TAN = MNO Aged Long Term Care
TJ = SSI Disabled, Medically Needy Only	TAW = MNO Aged Waiver
TD = Medically Needy Only, General Assistance	TJN = MNO Disabled Long Term Care

Benefits	Full Benefit Group Codes A, C, D, J, M, PC, PA, PD, PJ, PK, PM, PU, PS, PH, PI, PMN, PMW, PJN, PJW, PAN, PAW, PCW, PCN, U	Limited Benefit Group Codes TA, TC, TJ, TM, TU, TJW, TAN, TAW
Ambulance Service	Covered	Covered
Corrective Lenses	Covered	Covered
Dental	Covered	Covered (Limited Benefit varies by benefit)
Inpatient Care	Covered	Covered
Medical Supplies (DME and Orthotics)	Covered	Covered
Mental Health/Substance Abuse through BH-MCO or County	Covered	Covered
OB/GYN Care	Covered	Covered
Outpatient Diagnostic Testing (CT/MRI/MRA)	Covered	Covered
Outpatient Diagnostic Testing (Nuclear Cardiology, Bone Densitometry)	Covered	Covered
Physical Therapy	Covered	Covered
Prescription Drugs	Covered	Covered
Primary Care Practitioner	Covered	Covered
Renal Dialysis	Covered	Not Covered
Routine Eye Exams	Covered	Covered
Short Stay Unit/SPU Procedures	Covered	Covered
Specialty Care Practitioner	Covered	Covered
Vitamins	Covered	Covered
Well Baby Visits/Immunizations	Covered	Covered

Covered Benefits

Covered benefits are NOT limited to the listing that follows. Please contact Gateway’s Provider Servicing Department at 1-800-392-1145 with any questions regarding services not listed.

Audiology and Speech Therapy

Gateway members under the age of 21 are eligible to receive audiology services including hearing aids and ear molds.

Please refer to the Referrals and Authorizations Section of this Manual for additional information regarding Audiology and Speech Therapy.

Chiropractic Services

Please refer to the Referral and Authorization Section of this Manual for information regarding Chiropractic Services.

Dental

Dental care is provided at 100% of eligible Medical Assistance benefits for members under 21. For members 21 and over, Gateway offers two benefit packages depending upon the member’s dental coverage with Medical Assistance. For members eligible for full dental benefits under Medical Assistance, Gateway provides all of the same benefits covered under the Medical Assistance Program. For those members who are eligible for only limited benefits under Medical Assistance, Gateway provides the same level of benefits as the Medical Assistance Program, as well as additional benefits for routine dental care and treatment.

Gateway contracts with Dental Benefit Providers, Inc. to provide covered dental services to members. Gateway’s Member Services Department is available to provide information regarding the participation status of individual practitioners.

Members may seek routine services from their dentist without a referral from their primary care practitioner. The dentist may refer a member to a participating dentist for specialty care services that are not covered by the Dental Program, such as orthodontics for members through age 20.

The extraction of impacted wisdom teeth (bony or soft tissue impaction) is a covered dental benefit for Gateway members, and is covered through Dental Benefit Providers. All authorizations for the procedure and for any ancillary services, i.e., anesthesia, must be obtained from the member’s dentist and Dental Benefit Providers at 1-800-445-9090. Extraction of asymptomatic third molars is not a covered benefit.

Certain oral surgery procedures, which involves cutting the jaw, are covered as medical procedures through Gateway’s panel of oral surgery practitioners. A listing of Gateway participating Oral and Maxillofacial Surgeons is available via Gateway’s Specialist Directory and the On-line Provider Directory found at www.gatewayhealthplan.com . Members requiring these services must be referred by their primary care practitioner to a Gateway participating oral surgeon. The oral surgeon is responsible for authorizing surgical procedures performed in a hospital Short Procedure Unit (SPU) with Gateway prior to rendering services. Surgical services provided in the office are not subject to authorization procedures.

Even if the services the practitioner wishes to perform are not listed in this section, Gateway may cover them. Please contact Gateway’s Provider Services Department at 1-800-392-1145 to verify coverage of the specific services.

Durable Medical Equipment, Orthotics and Prosthetics

Refer to the Referral and Authorization Section of this Manual for additional information regarding Durable Medical Equipment, Orthotics and Prosthetics.

Dialysis

Coverage of Dialysis Services for Gateway members is limited by Medical Assistance to those members eligible for Medical Assistance under certain federally funded categories.

Refer to the Referral and Authorization Section of this Manual for additional information regarding Dialysis.

Family Planning

All family planning benefits provided under Gateway are administered and contracted for by Family Health Council. If a Gateway member presents for family planning benefits, please be aware of the following:

The member’s Gateway eligibility can be verified by calling 1-800-642-3515.
Family planning patients DO NOT need a referral from their primary care practitioner under federal mandate. If a member becomes pregnant, she may self-refer to her OB/GYN for prenatal care. The Department of Public Welfare permits members to see any participating or non-participating practitioner for family planning services.
The Sterilization Consent Form (MA-31), found in the Forms and Reference Materials Section of this manual, must be obtained from the patient thirty (30) days prior to the procedure.
The appropriate documentation must be obtained for abortion services.
Family planning procedures MUST BE PRE-AUTHORIZED at least five (5) working days prior to the procedure by calling Family Health Council at 1-800-532-9465.

Items to note include:

Post-partum tubal ligations MUST BE PRE-AUTHORIZED by Family Health Council.
All outpatient laboratory testing should be ordered with a prescription through the member’s primary care practitioner or OB/GYN according to the primary care practitioner’s designated laboratory.
Depo-Provera may be administered by Gateway practitioners and billed to Gateway. The following codes should be used when billing for Depo-Provera:
- J1055—150 mg drug
- Z9985—injection of the drug
- W6003—annual Depo-Provera visit (Note: This is an MA Local Code; therefore, the code will be obsolete sometime in 2005.)

Subsequent visits should be billed with an Evaluation and Management Code or family planning clinic visit code. A supply of Depo-Provera can be obtained through MedMark Specialized Pharmacy Services at 1-888-347-3416. MedMark will bill Gateway directly for the supply of Depo-Provera.

Reversals of tubal ligations, vasectomies and infertility treatments ARE NOT COVERED by the Pennsylvania Medical Assistance Program or Gateway.

Pregnancy termination service coverage follows that established by the Department of Public Welfare. Only those cases that are related to rape, incest or endangerment to the life of the mother are covered. A provider must complete the appropriate Department of Public Welfare physician certification forms, i.e. MA-3, MA-368 or MA-369 and submit the completed form to Family Health Council. Family Health Council will issue an approval for payment once the appropriate forms are received and reviewed. Family Health Council may be contacted at 1-800-532-9465. The appropriate forms may be faxed to 412-201-4701.

If a Gateway practitioner is interested in contracting with Family Health Council to provide family planning services, the practitioner should call Provider Servicing at 1-800-392-1145 for further information.

Home-Based Services

Private Duty Nursing services, when medically necessary, are covered for Gateway members under the age of 21. Gateway members over the age of 21 are not eligible to receive private duty nursing services.

Gateway’s Case Management Department coordinates medically necessary private duty nursing services with the ordering practitioner and the home health care provider. The Case Management Department can be reached at 1-800-642-3550.

Please note: Gateway cannot accept bills in half-hour increments. Providers must bill in whole hours.

Hospice Services

Should a member be in need of hospice care, the primary care practitioner, attending physician, hospital Utilization Review Department, or hospice agency should contact Gateway’s Utilization Management Department. Gateway will coordinate the necessary arrangements between the primary care practitioner and the hospice provider in order to ensure continuity of the member’s care.

To obtain authorization please call Gateway’s Utilization Management Department at 1-800-392-1146.

Mental Health/Substance Abuse Services

Mental Health and Substance Abuse Services are available to Gateway members on a self-referral basis. Access to these services is administered to members depending on where the member resides. Please refer to the Quick Reference Section of this Manual for the appropriate telephone numbers.

Non-emergent, medically necessary ambulance transport, in addition to any non-formulary or prior authorized medications require an authorization.

Skilled Nursing Facility

Refer to the Referral and Authorization Section of this Manual for additional information regarding Skilled Nursing Facilities.

It should be noted, per Gateway’s agreement with the Department of Public Welfare, that Gateway will be financially responsible for thirty (30) days of nursing coverage. On the thirty-first (31^st) day, the ordering practitioner should begin billing the Medical Assistance Program since the member will be automatically disenrolled from Gateway.

Prescription Drug and Over-the-Counter Benefits

Select over-the-counter (OTC) pharmaceuticals including vitamins are a covered benefit for all members. Members must have a written prescription for each OTC pharmaceutical/vitamin, and the prescription must be filled by a Gateway participating pharmacy.

Full prescription drug benefits are available to those members who are under 21 years of age. For members age 21 and over there are two pharmacy benefit packages that are based on the member’s category of Medical Assistance eligibility.

Full Benefits	MA Categories Categorically Needy is administered for all of the prescriptions provided under the full Gateway prescription drug coverage. [Categories A, C, D, J, M, PA, PC, PD, PJ, PK, PM, PS, PU, U, PH, PI, PMN, PJN, PJW, PAN, PAW, PCN, PCW]
Limited Benefits	MA Categories of Medically Needy are administered only for vitamins, birth control, insulin, and insulin syringes [Categories TA, TC, TE, TJ, TU, TM, TJN, TAN, TAW]

Prescriptions must be filled by a Gateway participating pharmacy in order to be covered by Gateway. When a member travels outside of the Gateway service area and must access a non-participating pharmacy, the member should utilize any Argus Pharmacy and the claims should be billed to Gateway via the Argus Network.

Gateway contracts with Argus to develop a network of chain and independent pharmacies in order to provide pharmaceuticals to Gateway members. A list of participating pharmacies can be obtained by contacting Gateway’s Member Services Department at 1-800-392-1147. Prescriptions are available at no cost to members who are eligible for pharmacy coverage when written by a Gateway practitioner. Gateway utilizes a closed formulary. Practitioners are requested to prescribe medications included in the formulary whenever possible.

Some pharmaceuticals, although listed on the formulary, require prior authorization to be covered. If use of a formulary medication is not medically advisable for a member, you must initiate a Request for Non-Formulary Drug Coverage. Please refer to the Forms and Reference Materials Section of this manual for a copy of this form. Please refer to the Referral and Authorization section of this manual for information regarding requesting non-formulary drugs.

Drugs Covered Under the Full Benefit

Legend drugs listed in the closed formulary
Non-formulary drugs which have been granted a formulary exception for an individual member
Non-legend drugs listed in the Gateway Over-The-Counter Formulary Section
Insulin/disposable syringes/needles
Disposable urine/blood glucose/acetone testing agents
Compounded medication of which at least one ingredient is a prescription drug
Contraceptives

The limit is an amount normally prescribed by the practitioner, but must not exceed a 34-day supply. Prescriptions can be refilled up to 12 months from the original prescription date as authorized by the practitioner.

Exclusions (Applicable regardless of category of Medical Assistance Health Benefits package):

Non-legend drugs other than those specifically listed in the Over-The-Counter Formulary below
DESI Drugs: less than effective drugs as defined by the Federal Drug Administration
Non-rebated Manufacturers (Gateway excludes coverage for any drug marketed by a drug company who does not participate in the Medicaid Drug Rebate Program)
Impregnated gauze (and similar or related products)
Non-legend soaps, cleaning agents, dentifices, mouthwashes, douche solutions, diluents, ear wax removal agents, deodorants, linaments, antiseptics, irrigants, emollients, and other personal care and medicine chest items
Non-legend aqueous saline solutions for any use other than intravenous administrations
Non-legend water preparations such as distilled water, water for injections, and identical, similar or included products
Minoxidil (Rogaine) for the treatment of alopecia
Drugs prescribed for cosmetic purposes
Therapeutic devices or appliances, including needles, syringes, support garments and other medicinal substances, regardless of intended use, except those listed above
Charges for administration or injection of any drug
Prescriptions which an eligible person is entitled to receive without charge from any Worker’s Compensation Claim
Drugs prescribed for investigational or experimental purposes
Biologicals, blood or blood plasma
Non-legend drugs in the form of troches, lozenges, throat tablets, cough drops, chewing gum, mouthwashes, and similar items
Non-legend food supplements
Any prescription refilled in excess of the number specified by the practitioner
Anorexients
Fertility Drugs

Gateway Over-The-Counter Formulary

For coverage, drugs must be written as a prescription. Drugs are listed alphabetically by category with their corresponding formulary chapter noted. Specific OTC drugs are listed as examples and are not inclusive of all covered products.

ANALGESICS
Acetaminophen	Acetaminophen combinations
Aspirin	Aspirin combinations
Non-steroidal Anti-Inflammatory Agents	Salicylate

DERMATOLOGICAL/TOPICAL THERAPY
Anesthetics (benzocaine, dibucaine, lidocaine, cyclomethycaine, pramozine, tetracaine)	Antibacterials (bacitracin, neomycin, triple antibiotic preparation, povidone-iodine, tetracycline)
Anti-Inflammatory Agents (hydrocortisone 1%)	Dermatological Baths (colloidal oatmeal)
Fungicidals (clotrimazole, miconazole, tolnaftate, terbinafine, undercyclenic acid, clioquinol, salicylic acid, triacetin)	Wet Dressings (aluminum acetate)
Tar Preparations	Scabicides/Pediculicides

ENODCRINE/DIABETES
Insulin	Insulin Needles and Syringes
Diagnostic Devices	Diabetic Supplies (lancets, alcohol swabs)

GASTROENTEROLOGY
Antacids	Antidiarrheals (kaolin-pectin combinations, loperamide)
Antiflatulents (simethicone)	Antinauseants (cyclizine, meclizine, dimenhydrinate)
Laxatives and Stool Softeners	Histamine-2 Receptor Antagonists
Prilosec OTC

OBSTETRICS AND GYNECOLOGY
Contraceptives (condoms, contraceptive jellies)	Contraceptive Devices
Vaginal Fungicides

OPHTHALMIC PREPARATIONS
Ocular Lubricants (polyvinyl alcohol or cellulose derivatives)	Phenylephrine .12%
Sodium Chloride

RESPIRATORY, ALLERGY, COUGH AND COLD
Antihistamines (diphenhydramine, loratadine)	Bronchodilators
Cough and Cold Products	Nasal Preparations (naphazoline, xylometazoline, oxymetazoline, Phenylephrine)
Saline for Inhalation

VITAMINS, HEMATINICS AND ELECTROLYTES
Vitamins	Prenatal Vitamins
Calcium Salts	Iron Products (not including long-acting products)
Nicotinic Acid	Oral Electrolyte Mixtures

SMOKING CESSATION PRODUCTS
Nicotine Replacement

Medical Supplies

Please contact Gateway’s Provider Servicing Department for information regarding Medical Supplies.

Rehabilitation

Refer to the Referral and Authorization Section of this Manual for additional information regarding Rehabilitation.

Vision

Gateway members have coverage for eye examinations. Gateway has subcontracted with Davis Vision to administer its routine vision benefits, providing Gateway members with access to the largest number of vision care practitioners possible. Gateway’s Member Services Department is available to provide information regarding the participation status of individual practitioners.

All Gateway members have coverage for eye examinations and/or contact lens fittings. Members age 21 and under can receive additional medically necessary eye examinations.

Members under the age of 21 are eligible for two basic pairs of glasses and one pair of contact lenses per calendar year. Replacement pairs are covered if medically necessary. Members 21 years of age and older are eligible for one basic pair of glasses or one pair of contact lenses per calendar year.

For all members, cosmetic tinted contacts are excluded.

If a member chooses frames or specialty contact lenses costing more than Gateway allows, the member may be charged an additional fee.

Gateway members may self-refer to any Davis Vision participating vision care practitioner for a routine refractive eye exam, eyeglasses, and contacts if medically necessary. The primary care practitioner does not need to issue a Gateway referral.

Should the member require additional medical services, the member will need a referral from the primary care practitioner to a Gateway participating ophthalmologist or a Davis Vision optometrist. When referring to a optometrist for non-routine services a referral form is required.

Requests for services outside the vision benefit plan must be submitted to Gateway’s Utilization Management Department for review.

Members Rights and Responsibilities

All Gateway members have rights and responsibilities. They are as follows:

GATEWAY HEALTH PLAN MEMBERS’ RIGHTS AND RESPONSIBILITIES STATEMENT

Member Rights

As a Gateway Member, you have the right to:

Get information about Gateway, the services Gateway provides, doctors and other health care providers giving you care, and your rights and responsibilities as a Gateway member.Be treated with respect and recognition of dignity and right for privacy when receiving health care.
Work with your doctor or other health care provider in making decisions about your health care and to express preferences about future treatment decisions.
Openly discuss without any limitations by Gateway appropriate or medically necessary treatment choices for your condition with a doctor or other health care provider, including treatment options, risks of treatments, alternative therapies, and consultations or tests that may be self administered, regardless of the cost or if it is a benefit.
Receive your medical and nursing care without regard to race, color, religion, sex, age, disability, national origin, or without regard to whether you have an advance directive.
Pick your own doctor from Gateway’s network of doctors.
Refuse care from certain doctors.
File a complaint or grievance about Gateway or the care it provides.
Make recommendations regarding Gateway’s members’ rights and responsibilities policies.
Request a fair hearing from the Department of Public Welfare.
Prepare a Living Will and/or Advance Directive.
See, or have your medical record copied, within Federal and State laws, and to request that your medical record be changed or corrected within Federal laws.
Have your medical records kept private and confidential.

Member Responsibilities

As a Gateway Member you have a responsibility to:

Give information to your doctor, other health care provider, or Gateway so they can provide care to you.
Follow the instructions and treatment plans that you agreed on with your doctor or other health care provider.
Provide consent to healthcare providers and Gateway to help them manage your care, to improve your health or for research.
Understand your health problems. As much as you can, take part in making a plan for treatment goals with your doctor or other health care providers.
See the doctor you picked on a regular basis.
Treat the people giving you medical care with the same respect and kindness you expect for yourself.

Si desea recibir una copia de esta información en español, por favor llame al numero 1-800-392-1147.

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Last Updated: 1/1/2010