Combined-SoonerCare Benefit Guide. expansion with Choice …

1 BENEFITS GUIDE. SoonerCare SoonerCare SoonerCare Please note: SoonerCare SoonerCare Traditional & Traditional Choice . All covered services Traditional Choice Choice expansion expansion must be medically necessary. Children Under Adults 21 and Adults 21 and Adults 19 64 Adults 19 64. 21 Over Over covered covered covered covered covered Ambulance or Emergency Emergency Emergency Emergency Emergency Emergency Transportation Only Only Only Only Only N/A N/A. Child Health Wellness Screens For individuals For individuals 21 and over 21 and over (Including health and immunization history; covered covered physical exams; various covered N/A N/A. expansion expansion health assessments and adults 19 20 adults 19 20 are counseling; lab and are eligible to eligible to screening tests; and receive EPSDT receive EPSDT.)

2 Necessary follow-up care.) services . services . SoonerCare SoonerCare SoonerCare SoonerCare SoonerCare Please note: Traditional & Traditional Choice . Traditional Choice All covered services Choice expansion expansion must be medically necessary. Children Under Adults 21 and Adults 21 and Adults 19 64 Adults 19 64. 21 Over Over covered covered covered covered Preventive Preventive Preventive Preventive (dental (dental (dental Dental services (dental cleanings and cleanings and cleanings and cleanings and (Non-exempt SoonerCare fluoride); fluoride); fluoride);. fluoride);. adult members will be covered restorative restorative restorative restorative charged a $4 copay per (silver and (silver and (silver and (silver and visit for non-emergency tooth-colored tooth-colored tooth-colored tooth-colored dental services .))))

3 Fillings); full fillings); full fillings); full fillings); full and and partial and partial and partial partial dentures dentures and dentures and dentures and and extractions. extractions. extractions. extractions. Diabetic Supplies (100 glucose strips and lancets per month; one covered spring-loaded lancet covered covered covered covered device; three Plus one glucometer per $4 per claim. $4 per claim. $4 per claim. $4 per claim. replacement batteries per year. Additional year. supplies require prior authorization.). SoonerCare SoonerCare SoonerCare SoonerCare SoonerCare Please note: Traditional & Traditional . Traditional Choice Choice expansion All covered services Choice expansion must be medically necessary. Children Adults 21 and Adults 21 and Adults 19 64 Adults 19 64.

4 Under 21 Over Over covered covered covered covered covered When When When When prescribed When prescribed by prescribed by prescribed by by medical prescribed by medical medical medical provider and Durable Medical medical provider and provider and provider and may require Equipment provider and may require may require may require prior may require prior prior prior authorization. prior authorization. authorization. authorization. authorization. $4 copay per $4 copay per $4 copay per $4 copay per claim. claim. claim. claim. Emergency Department covered covered covered covered covered (ER services ). covered covered covered covered covered Birth control Birth control Birth control Birth control Birth control information information information information information and and supplies; and supplies; and supplies; and supplies.

5 Family Planning services supplies; pap pap smears; pap smears; pap smears; pap smears;. smears;. and pregnancy pregnancy pregnancy pregnancy tests;. pregnancy tests; tubal tests; tubal tests; tubal tubal ligations tests. ligations and ligations and ligations and and vasectomies. vasectomies. vasectomies. vasectomies. SoonerCare SoonerCare SoonerCare SoonerCare SoonerCare Please note: Traditional & Traditional . Traditional Choice Choice expansion All covered services Choice expansion must be medically necessary. Children Adults 21 and Adults 21 and Under 21 Over Adults 19 64 Adults 19 64. Over covered as PT, covered as PT, ST, ST, OT visits OT visits (In addition to (In addition to the therapy the therapy visit visit Benefit .))

6 Benefit .). No prior No prior Habilitation services covered No coverage No coverage authorization authorization required; 15 required; 15 visits visits per year per year per per discipline in discipline in hospital hospital outpatient; $4 outpatient; $4. copay per visit. copay per visit. covered covered covered covered Evaluation Evaluation Evaluation only. covered only. only Evaluation only Evaluations, Hearing aids Hearing services Hearing aids Hearing aids Hearing aids hearing aids covered when covered when covered when covered when and supplies. provided within provided within provided provided within nursing nursing within nursing nursing facilities facilities facilities facilities Home Health Care services covered covered covered covered covered covered covered Hospice covered No coverage No coverage Effective Oct.

7 1, Effective Oct. 1, 2021 2021. SoonerCare SoonerCare SoonerCare SoonerCare SoonerCare Please note: Traditional & Traditional Choice . Traditional Choice All covered services Choice expansion expansion must be medically necessary. Children Under Adults 21 and Adults 21 and Adults 19 64 Adults 19 64. 21 Over Over covered covered covered covered Inpatient $10 per day for $10 per day for $10 per day for $10 per day for Hospital covered first seven first seven days first seven days first seven days . services days $5 on $5 on the $5 on the $5 on the eighth the eighth eighth day. eighth day. day. day. covered covered covered covered As As recommended Immunizations As As recommended for adults; $4 per recommended recommended for adults; $4.

8 (As recommended by the covered date of service. for adults; $4 for adults; $4 per date of Advisory Committee of No copay if per date of per date of service. No Immunization Practices) service is service. service. copay if service preventive. is preventive covered covered covered covered $4 per visit. No $4 per visit. No Laboratory and X-ray covered $4 per visit. $4 per visit. copay if service copay if service is is preventive. preventive. Nursing Facility services covered covered covered covered covered covered covered covered covered covered No copay if No copay if Mammograms service is service is preventive. preventive. Nurse Midwife services covered covered covered covered covered SoonerCare SoonerCare SoonerCare SoonerCare SoonerCare Please note: Traditional & Traditional Choice .

9 Traditional Choice All covered services Choice expansion expansion must be medically necessary. Children Adults 21 and Adults 21 and Adults 19 64 Adults 19 64. Under 21 Over Over Medication Assisted covered covered covered covered covered Treatment Some drugs Some drugs Some drugs Some drugs Includes: Some drugs may may require may require may require may require require prior Drugs and agents used prior prior prior prior authorization. for substance use disorder authorization. authorization. authorization. authorization. OTP services treatment and opioid OTP services OTP services OTP services OTP services require prior treatment programs require prior require prior require prior require prior authorization. (OTPs). authorization.

10 Authorization. authorization. authorization. covered covered covered covered With prior With prior With prior With prior authorization. authorization. Mental Health or covered authorization. authorization. Copay for Copay for Substance Use Disorder Copay for Copay for With prior inpatient - inpatient - Medical Detoxification inpatient - $10 inpatient - $10. authorization. $10 per day, $10 per day, Inpatient per day, up to per day, up to a up to a up to a a maximum of maximum of maximum of maximum of $75. $75. $75. $75. covered covered covered covered With prior With prior With prior With prior Mental Health or covered authorization. authorization. authorization. authorization. Substance Use Disorder With prior Some services Some services Some services Some services Outpatient authorization.