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FAQs

SoonerCare

SoonerCare is Oklahoma’s Medicaid program and is run by the Oklahoma Health Care Authority. SoonerCare is insurance that helps pay for medical care.  

There are several different factors that determine if a person qualifies for SoonerCare. Click here to view SoonerCare eligibility guidelines. We encourage everyone to apply online at mysoonercare.org. At the end of the application, you will receive an approval or denial immediately. 

If you are blind, disabled or over the age of 65 and you do not have SoonerCare, apply at OKDHSlive.org. You can also call your local DHS office for an appointment. 

SoonerCare will pay for most medical services, but not all. If you do not know if a service is covered by SoonerCare, ask your provider or call the SoonerCare helpline at 800-987-7767. Ask your provider for the procedure code of the service you are wanting and have it available when you call the SoonerCare helpline.

Benefits

Yes! Please make an appointment with your PCP after you are approved for SoonerCare. If additional providers are needed, your PCP will help you. 

This is not a complete list. Some of the types of services SoonerCare will pay for are:

  • Urgent care centers
  • Diabetic supplies
  • Birth control
  • Tubal ligations
  • Vasectomies
  • Emergency room
  • Pregnancy tests
  • Pap smears
  • Immunizations (shots)
  • Lab tests
  • Substance abuse detoxification
  • Substance abuse treatments
  • Mental health treatments
  • Pharmacy services
  • Pregnancy services
  • Stop smoking products

SoonerCare will pay for most medical services, but not all. If you do not know if a service is covered by SoonerCare, ask your provider or call the SoonerCare helpline at 800-987-7767. Ask your provider for the procedure code of the service you are wanting and have it available when you call the SoonerCare helpline.

Vision services are not covered for adults, but eye diseases and eye injuries would be covered. Speak to your PCP to start treating eye issues. 

SoonerCare will pay for some dental services. Cleanings, fluoride, fillings, teeth removal, and full and partial dentures are some of the covered services.  

Sometimes it is hard to know what to ask. Here are some questions you might ask. 

When a test is suggested, ask:

  • What is the reason for the test?
  • What problem are we looking for?
  • What will the test tell us?
  • What happens if the test finds a problem?
  • What happens if I do not get the test?

When a treatment is suggested, ask:

  • What is the problem and how serious is it?
  • When do we start the treatment?
  • Would you tell me about the treatment?
  • Will this treatment solve the problem?
  • What are the side effects?
  • What other types of treatment do we have as an option?

Cost Sharing and Copays

Cost sharing is the monthly limit of total copays a member will pay. This limit is 5% of the total household income reported to SoonerCare. 

The monthly cost sharing limit is different for everyone. It’s based on 5% of the total household income reported to SoonerCare. If you make $0 a month, your cost sharing limit would be $0. If you make $500 a month, your cost sharing limit would be $25 a month. SoonerCare will keep track of this for you. 

A copay is the fee you pay to a provider or pharmacy at the time you get the service. The standard copay for SoonerCare is $4.00. 

A copay is the fee you pay to a provider or pharmacy. The cost sharing limit is the most money you will spend monthly on copays. The standard copay for SoonerCare services is $4.00. 

If your reported income is $0 a month, your cost sharing limit would be $0 a month. This means you would not have any copays because your cost sharing is met for the month. 

If your reported income is $500 a month, your cost sharing limit would be $25 a month. This is 5% of the reported income. That would mean you are responsible for paying copays at your appointments and at the pharmacy until your total copays hit $25 in the same month. Once your copays totaled $25, you would have hit your cost sharing limit for the month and would not be responsible for any other copays that month. The cost sharing limit resets every month.  

This means your copays to your provider or pharmacy will never total more than your household’s cost sharing limit a month. After you reach this limit, you will no longer pay copays through the end of the month. Each month your cost sharing limit will reset automatically. The standard copay is $4.00 per visit. You’re expected to pay your copay until your monthly cost sharing limit is met.  

No, cost sharing is not a bill. It is a limit of total copays monthly. 

Patient Centered Medical Home (PCMH)/Primary Care Provider (PCP)

PCMH stands for Patient Centered Medical Home. PCP stands for primary care provider. Your PCP works for your PCMH. 

Your PCP will help discover and treat common medical issues, provide you with preventive care, refer you to a specialist when needed, and help you meet your health goals.

You need to talk to your PCP about any other providers you think you may need. A referral from your PCP is needed to see a specialist. SoonerCare may not pay for services if a referral is not on file. 

A referral is a documented recommendation from your PCP that states you need to see a specialist. You PCP will handle all referrals for you. 

Yes, you have the right to choose your PCP and may change PCPs at any time. You can do this by logging into mysoonercare.org. You can also call the SoonerCare helpline at 800-987-7767.

Your PCP cannot stop seeing you as a patient because your health gets worse. However, your PCP can ask to dismiss you if you:

  • Are disruptive;
  • Are verbally abusive to the provider, staff, or others;
  • Regularly miss appointments with telling your PCMH at least 24 hours in advance;
  • Were dismissed from a different provider in the same office;
  • No longer qualify for SoonerCare;
  • Do not follow your PCP’s treatment advice.

A primary care physician (PCP) is an advocate for your health. If you decide you do not want a PCP to help manage your health, you can remove the PCP from your account. Without a PCP, you can see any contracted SoonerCare provider, but the number of visits you can make is limited to four a month.

Emergency Services

An emergency means you could die or be permanently injured or disabled if you do not receive proper care immediately.

This is not a complete list. Some examples of an emergency are:

  • Drug overdose
  • Sexual assault or abuse
  • Decreased or loss of consciousness
  • Not being able to respond to questions
  • Feeling like you might hurt yourself or others
  • Difficulty breathing
  • Extreme bleeding
  • Broken bones
  • Accidental poisoning
  • Burns with blisters
  • Pain or tightness in chest

Contact 911 immediately or go to your nearest emergency room. As soon as you can, call your PCP and alert them of the emergency. They will help you with medical care after your emergency room visit. 

SoonerRide

SoonerRide is a free ride service for SoonerCare members who need help getting to medical appointments. SoonerRide is for non-emergencies only. 

Yes, you need to call 3 business days before your scheduled appointment to set up your ride. To schedule a ride, call 877-404-4500.

SoonerRide will help you get to your appointments as long as you live within 45 miles of your PCP office. 

Last Modified on Mar 30, 2022
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