SECTION 317:35-3-1. Reimbursement

(a)   Payment eligibility. In order for the Authority to make payment for SoonerCare services, the individual must be determined eligible to have such payment made by:

(1)   having eligibility previously determined, or

(2)   making application for SoonerCare at the time the medical services is requested, and having eligibility determined at that time.

(b)   Member lock-in. SoonerCare members who have demonstrated utilization above the statistical norm, during a 6-month period, may be "locked-in" to a prescriber and/or one pharmacy for medications classified as controlled dangerous substances. If OHCA has determined that SoonerCare has been over-utilized, the member is notified, by letter, of the need to select a prescriber and/or pharmacy and of their opportunity for a fair hearing. If the member does not select a prescriber or pharmacy, one is selected for her/him. "Locked-in" members may obtain emergency services from a physician and/or an emergency room facility in the event of a medical emergency.

[Source: Added at 12 Ok Reg 753, eff 1-6-95 through 7-14-95 (emergency); Added at 12 Ok Reg 3133, eff 7-27-95; Amended at 20 Ok Reg 646, eff 2-1-03 (emergency); Amended at 20 Ok Reg 1943, eff 6-26-03; Amended at 20 Ok Reg 2775, eff 7-1-03 (emergency); Amended at 21 Ok Reg 2234, eff 6-25-04; Amended at 32 Ok Reg 1125, eff 8-27-15]