Traditional SoonerCare does not cover routine eye exams for adults age 21 and older, and it does not pay for eyeglasses, contact lenses, or frames tied to refractive errors. Whether SoonerCare covers eye exams for adults depends on which program you are in: if you are enrolled in one of the three SoonerSelect managed care plans, you get an annual routine exam and an eyewear allowance as a value-added benefit. Medically necessary treatment of eye disease or injury is covered under either path.
What Traditional SoonerCare Excludes for Adults
Oklahoma’s administrative code is blunt. For members 21 and older, “there is no provision for routine eye exams, examinations for the purpose of prescribing glasses or for prescribing visual aids, for the determination of refractive state or treatment of refractive errors, or for the purchase of lenses, frames, or visual aids.”1Oklahoma.gov. OHCA Administrative Code, Title 317 – Adult Eye Care Provisions The SoonerCare benefits page lists optometric and optical services, including eyeglasses, only under services for children.2Oklahoma.gov. SoonerCare Benefits
Coverage is decided by the purpose of the visit, not the outcome. A routine exam stays classified as routine even if the optometrist finds disease during the visit. Providers who perform non-covered vision services for adults must give the member written notice ahead of time and can bill the patient directly for refractive exams and eyewear.1Oklahoma.gov. OHCA Administrative Code, Title 317 – Adult Eye Care Provisions
What Traditional SoonerCare Does Pay For
Adults on traditional SoonerCare are covered for medical services that are “reasonable and necessary for the diagnosis and treatment of illness or injury” and for “treatment of eye disease not related to refractive errors.”1Oklahoma.gov. OHCA Administrative Code, Title 317 – Adult Eye Care Provisions A referral from your medical home is required.3Oklahoma.gov. SoonerCare Member Handbook
Some optical supplies are also covered when medically necessary:
- Bandage contact lenses for specific conditions such as aphakia, keratoconus, and post-keratoplasty.4Oklahoma.gov. OHCA Guidelines for Ocular Lens
- Corrective lenses and frames when there is a significant prescription change or replacement is needed from normal wear, limited to two pairs per year; more requires prior authorization.5Oklahoma.gov. Corrective Lenses and Optical Supplies
Progressive lenses, aspheric lenses, tints, coatings, and photochromic lenses are excluded for adults and can be billed to the patient.4Oklahoma.gov. OHCA Guidelines for Ocular Lens
Routine Vision Under SoonerSelect Plans
Most Oklahoma Medicaid members are now in SoonerSelect, the state’s managed care system. Each plan must cover everything traditional SoonerCare covers, and each may add extra benefits.6Oklahoma.gov. About SoonerSelect All three health plans have added routine adult vision. Oklahoma Complete Health describes its version as expanding “the state’s covered vision services for members” with an annual exam and an eyewear allowance.7OklahomaCompleteHealth.com. Benefits Overview The specifics differ by plan, according to OHCA’s value-added benefit comparison chart.8Oklahoma.gov. SoonerSelect Health VAB Comparison Chart
Aetna Better Health of Oklahoma
Adults get $75 toward an annual eye exam and $150 every two years toward glasses or contacts.
Humana Healthy Horizons in Oklahoma
One annual eye exam at no cost to the member.9Humana.com. Oklahoma Medicaid Vision Coverage Every two years, members choose either eyeglasses with non-high-index polycarbonate lenses and a $100 frame allowance, or a $100 allowance toward contact lenses. Costs above the allowance are the member’s responsibility.10Humana.com. Value-Added Benefits
Oklahoma Complete Health
A complete eye exam with refraction once per calendar year, renewing July 1.11OklahomaCompleteHealth.com. Member Vision Benefits $150 toward glasses or contacts every two years, also renewing July 1.12OklahomaCompleteHealth.com. Value Added Benefits These benefits carry no copayment.
All three plans also cover medically necessary eye care for members of any age, including surgical services and post-cataract eyewear.
Finding a Vision Provider
If you are on SoonerSelect, you have to use a provider contracted with your specific plan. Each plan runs its own directory and member line:13Oklahoma.gov. SoonerSelect Provider Resources
- Aetna Better Health: AetnaBetterHealth.com/Oklahoma or 844-365-4385.
- Humana Healthy Horizons: Humana.com/Medicaid or 855-223-9868.
- Oklahoma Complete Health: OklahomaCompleteHealth.com or 833-752-1664.
Traditional SoonerCare members needing treatment for eye disease or injury can use the OHCA provider directory and should confirm the provider is accepting SoonerCare patients.14Oklahoma.gov. Find a Provider
Adult Eligibility for SoonerCare
Adults ages 19 to 64 qualify if household income is at or below 138 percent of the federal poverty level. For a single adult, the monthly income limit is $1,848.15Oklahoma.gov. Income Guidelines Enrollment is open year-round through HealthCare.gov, the SoonerCare website, or the SoonerCare Helpline at 1-800-987-7767.