The Recipient Restriction/Member Lock-In Program requires a member to use specific providers if the member has abused or overused his or her health care or prescription drug benefits. Highmark Wholecare works with DHS to decide whether to limit a member to a doctor, pharmacy, hospital, dentist or other provider.
Highmark Wholecare reviews the health care and prescription drug services you have used. If Highmark Wholecare finds overuse or abuse of health care or prescription services, Highmark Wholecare asks DHS to approve putting a limit on the providers you can use. If approved by DHS, Highmark Wholecare will send you a written notice that explains the limit. You can pick the providers, or Highmark Wholecare will pick them for you.
If you want a different provider than the one Highmark Wholecare picked for you, call Member Services. The limit will last for 5 years even if you change plans. If you disagree with the decision to limit your providers, you may appeal the decision by asking for a DHS Fair Hearing, within 30 days of the date of the letter telling you that Highmark Wholecare has limited your providers.
You can pick the providers, or Highmark Wholecare will pick them for you. If you want a different provider than the one Highmark Wholecare picked for you, call Member Services at 1-800-392-1147 (TTY users call 711 or 1-800-654-5984). The limit will last for 5 years even if you change HealthChoices plans.
Learn more about this program in the Member Handbook
