Gateway Health Plan®’s Recipient Restriction Program is a program to detect and deter member misutilization and/or fraud/abuse. This program restricts members to one 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 DPW (Department of Public Welfare) 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 Department of Public Welfare, 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 and/or fraud and/or abuse please contact our Pharmacy Services Department at 1-800-528-6738.