Recipient Restriction Program

Highmark Wholecare Protects You and Your Loved Ones

Highmark Wholecare’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.

Highmark Wholecare 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 Highmark Wholecare’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 Highmark Wholecare for assistance if this situation occurs.

This information is issued on behalf of Highmark Wholecare, coverage by Gateway Health Plan, which is an independent licensee of the Blue Cross Blue Shield Association. Highmark Wholecare serves a Medicaid plan to Blue Shield members in 13 counties in central Pennsylvania, as well as, to Blue Cross Blue Shield members in 14 counties in western Pennsylvania. Highmark Wholecare serves Medicare Dual Special Needs plans (D-SNP) to Blue Shield members in 14 counties in northeastern Pennsylvania, 12 counties in central Pennsylvania, 5 counties in southeastern Pennsylvania, and to Blue Cross Blue Shield members in 27 counties in western Pennsylvania.

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