Recipient Restriction Program

Gateway Health Plan^®’s Recipient Restriction Program is a program to detect and deter member misutilization, fraud and/or abuse. This program restricts members to one primary care physician (PCP) and/or one participating pharmacy of the member’s choice for a period of five years.

Gateway Health Plan^® contacts the member’s physician and pharmacy of choice to ask if they would be willing to accept a restricted member. Our program interfaces with the Department of Public Welfare (DPW) centralized Recipient Restriction Program. This enables DPW to continue the restrictions for a five-year period across the Pennsylvania Medical Assistance Program.

Once a member is identified for this program through referrals from participating pharmacies or physicians or generated utilization reports, a complete review of pharmacy and medical claims data is performed. Upon completion of review, if misutilization, fraud and/or abuse can be documented and has met the DPW approved restriction criteria, the member is recommended for restriction to a PCP and/or participating pharmacy. Upon approval from Gateway Health Plan^®’s Recipient Restriction Committee and the DPW, the member is then restricted or “locked-in” to one PCP and/or one participating pharmacy.

Please note: the restriction is not enforced in the case of an emergency. Please contact Gateway Health Plan^® for assistance if this situation occurs.

If you suspect member misutilization, fraud and/or abuse. Please contact our Pharmacy Services Department at 1-800-528-6738.