Recipient Restriction Program

Gateway Protects You and Your Loved Ones

Gateway Health’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 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 Human Services (DHS) centralized Recipient Restriction Program. This enables DHS 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 DHS approved restriction criteria, the member is recommended for restriction to a PCP and/or participating pharmacy. Upon approval from Gateway’s Recipient Restriction Committee and DHS, 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 for assistance if this situation occurs.

Need Help?

If you suspect improper prescription utilization, fraud and/or abuse, please contact our Pharmacy Services Department at: 1-800-392-1147 or our Special Investigations Unit at 1-800-685-5235.
You can also email us.

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