Benefit | Coverage | Note |
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Alternative Treatment for Pain Management | Covered | With prior authorization. 12 hours (or 48 units) of therapeutic exercises and activities. 12 visits of manual spinal manipulation. $4 copay per visit. Includes: therapeutic exercises and activities and manual spinal manipulation. |
Ambulance or Emergency Transportation | Covered | Emergency Only |
Child Health Wellness Screens | N/A For individuals 21 and over ---------- Covered Expansion adults 19–20 are eligible to receive EPSDT services. | (Including health and immunization history; physical exams; various health assessments and counseling; lab and screening tests; and necessary follow-up care.) |
Dental Services | Covered | Preventive (dental cleanings and fluoride); restorative (silver and tooth-colored fillings); full and partial dentures and extractions. (Non-exempt SoonerCare adult members will be charged a $4 copay per visit for non-emergency dental services.) |
Diabetic Supplies | Covered | (100 glucose strips and lancets per month; one spring-loaded lancet device; three replacement batteries per year. Additional supplies require prior authorization.) $4 per claim. |
Durable Medical Equipment | Covered | When prescribed by medical provider and may require prior authorization. $4 copay per claim. |
Emergency Department (ER services) | Covered | (ER services) |
Family Planning Services | Covered | Birth control information and supplies; pap smears; pregnancy tests; tubal ligations and vasectomies. |
Habilitation Services | Covered as PT, ST, OT visits | (In addition to the therapy visit benefit.) No prior authorization required; 15 visits per year per discipline in hospital outpatient; $4 copay per visit. |
Hearing Services | Covered | Evaluation only. Hearing aids covered when provided within nursing facilities |
Home Health Care Services | Covered | |
Hospice | Covered | |
Inpatient Hospital Services | Covered | $10 per day for first seven days – $5 on the eighth day. |
Immunizations | Covered | As recommended by the Advisory Committee of Immunization Practices; No copay |
Laboratory and X-ray | Covered | $4 per visit. No copay if service is preventive. |
Nursing Facility Services | Covered | |
Mammograms | Covered | |
Nurse Midwife Services | Covered | |
Medication Assisted Treatment Includes: Drugs and agents used for substance use disorder treatment and opioid treatment programs (OTPs). | Covered | Some drugs may require prior authorization. OTP services require prior authorization. |
Mental Health or Substance Use Disorder Medical Detoxification– Inpatient | Covered | With prior authorization. Copay for inpatient - $10 per day, up to a maximum of $75. |
Mental Health or Substance Use Disorder– Outpatient | Covered | With prior authorization. Some services may require a $3 copay. |
Organ Transplants | Covered | With prior authorization. |
Orthodontic Services | No Coverage | |
Outpatient Hospital and Surgery Services | Covered | If medically necessary. $4 copay per visit. |
Over-the-Counter Contraceptives | Covered | |
Personal Care | Covered | As prescribed in treatment plan. $4 copay per visit. |
Physician Services | Covered | 4 Visits Per Month Including any specialist visits. $4 copay per visit. *Expansion adults may exceed physician visit limits, if medically necessary and with prior authorization. |
Primary Care Provider/Primary Care Medical Home | Covered | *Expansion adults may exceed physician visit limits, if medically necessary and with prior authorization. $4 copay per visit. |
Pregnancy and Maternity Services (Including prenatal, delivery and postpartum) | Covered | *For Soon-to-be-Sooners, refer to the notes at the bottom of this page. |
Prescription Drugs | 6 Per Month Limit | Up to 2 brand-name. $4 copay for each prescription. $4 copay per visit. (Prenatal vitamins and smoking cessation products do not count toward prescription limits.) No copays for children and pregnant women. ** For Home and Community-Based Waiver Services copays, refer to the notes at the bottom of this document. |
Preventive care and screening | Covered | |
Prosthetics and Orthotics | Covered | Without limitations, when medically necessary and with prior authorization. $4 copay per prescription. |
Psychiatric Residential Treatment Facility | No Coverage For adults 21 and over. ---------- Covered For adults 19-20 | |
Inpatient Rehab Hospital | Covered | 90 days per individual per state fiscal year (July–June). May exceed day limits, if medically necessary with prior authorization. |
Routine Patient Cost in Qualifying Clinical Trials | Covered | With a coverage determination. Existing copay applies for the for the individual service/item provided. |
SoonerRide Transportation to nonemergency covered medical services | Covered | Transportation to nonemergency covered medical services |
Stop Smoking (Cessation) Products | No Duration Limits | For a member's use of FDA approved cessation products (except Chantix which has a 180 day limit). |
Substance Use Disorder Residential Treatment | Covered | With prior authorization. |
Therapy Services Physical (PT), Speech (ST), Occupational (OT) | PT, ST, OT | No prior authorization required; 15 visits per year per discipline in hospital outpatient; $4 copay per visit. May require prior authorization for expansion adults members 19-20. |
Urgent Care Center | Covered | |
Vision Services | Covered | For eye diseases or eye injuries only. |
SoonerCare Choice Expansion Benefits Guide
Expansion for Adults 19-64
*Soon-to-be-Sooners MEMBERS IN SOON-TO-BE SOONERS RECEIVE PREGNANCY AND MATERNITY SERVICES ONLY. THE INDIVIDUAL WHO IS COVERED FOR PREGNANCY-RELATED BENEFITS UNDER SOON-TO-BE-SOONERS RETAINS ELIGIBILITY UNTIL THE END OF THE PREGNANCY. SECTION 317:30-22-8 |
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Home and CommunityBased Services (HCBS)1915(c) Waiver Programs | HCBS members receive the SoonerCare Traditional services in addition to the HCBS services within the waiver program they are enrolled which are: ·Advantage Waiver Program Services ·Medically Fragile Program Services ·Community Waiver Program Services ·Homeward Bound Program Services ·In-Home Supports for Adults Program Services ·In-Home Supports for Children Program Services Members in HCBS waiver programs only pay copays for prescriptions as follows: $0.65 copay per drug costing $10.00 or less; $1.20 copay per drug costing $10.01-$25.00; $2.40 copay per drug costing $25.01-$50.00; $3.50 copay per drug costing $50.01 or more. |
The covered benefits list provided is not all-inclusive. All covered benefits must be medically necessary. Coverage of above benefits is dependent upon meeting requirements provided in accordance with various state and federal regulations. Please verify coverage or consult with a SoonerCare helpline representative prior to receiving services. Coverage, copays and limitations are subject to change. Updated December 19, 2022.