Medicaid members may be referred to and enrolled in the Restriction Program. This program provides safeguards against inappropriate and excessive use of Medicaid services.
Restriction staff uses the guidelines below to determine if a member should be in the Restriction Program. Meeting one or more of the following criteria over a 12-month period may mean that a member is misusing Medicaid covered services.
- Four or more Primary Care Providers (PCPs), non-affiliated, in a maximum of 12 eligible months, and/or four or more specialists seen outside a normal range of utilization
- Four or more pharmacies in a maximum of 12 eligible months
- Three or more providers (non-affiliated) prescribing abuse potential medications
- Six or more prescriptions filled for abuse potential medications
- Five or more non-emergent ED visits in 12 months
Patients selected for enrollment are informed of the reasons for the issuance of a Restriction Program card. They are then restricted to one Primary Care Provider and one pharmacy. For patients in the Restriction Program, Medicaid will only pay claims for services rendered by the providers listed on the card and by providers to whom the patient has been appropriately referred. However, emergency services are not restricted.
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