| Benefit | Coverage | Note |
|---|---|---|
| Alternative Treatment for Pain Management | Covered | Includes: therapeutic exercises and activities and manual spinal manipulation |
| Ambulance or Emergency Transportation | Covered | Emergency Only |
| Child Health Wellness Screens | Covered | (Including health and immunization history; physical exams; various health assessments and counseling; lab and screening tests; and necessary follow-up care.) |
| Dental Services | Covered | (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.) Plus one glucometer per year. |
| Durable Medical Equipment | Covered | When prescribed by medical provider and may require prior authorization |
| Emergency Department (ER services) | Covered | |
| Family Planning Services | Covered | Birth control information and supplies; pap smears; and pregnancy tests. |
| Habilitation Services | Covered | |
| Hearing Services | Covered | Evaluations, hearing aids and supplies. |
| Home Health Care Services | Covered | |
| Hospice | Covered | |
| Inpatient Hospital Services | Covered | |
| Immunizations | Covered | (As recommended by the Advisory Committee of Immunization Practices) |
| Laboratory and X-ray | Covered | |
| 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. |
| Mental Health or Substance Use Disorder– Outpatient | Covered | With prior authorization. |
| Organ Transplants | Covered | With prior authorization. |
| Orthodontic Services | Covered | With prior authorization. |
| Outpatient Hospital and Surgery Services | Covered | If medically necessary. |
| Over-the-Counter Contraceptives | Covered | |
| Personal Care | Covered | As prescribed in treatment plan. |
| Physician Services | Covered | |
| Primary Care Provider/Primary Care Medical Home | Covered | Unlimited medically necessary services. |
| 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 | Unlimited Coverage | (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 | With prior authorization. Orthotics are covered. |
| Psychiatric Residential Treatment Facility | Covered | With prior authorization. |
| Inpatient Rehab Hospital | Covered | |
| Routine Patient Cost in Qualifying Clinical Trials | Covered | With a coverage determination. |
| SoonerRide Transportation to nonemergency covered medical services | Covered | |
| 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. Starting at age 13. |
| Therapy Services Physical (PT), Speech (ST), Occupational (OT) | Covered | May require prior authorization. |
| Urgent Care Center | Covered | |
| Vision Services | Covered | |
Children's Benefits Guide
SoonerCare Traditional & Choice for Children Under 21
| *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 |
|
|---|---|
| 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.
Last Modified on
Jan 13, 2023
