Okla. Admin. Code § 365:40-5-21

Current through Vol. 42, No. 8, January 2, 2025

Section 365:40-5-21 - Supplemental health care services

Supplemental health care services of an HMO may include the following:

(1) Corrective appliances and artificial aids.

(2) Eyeglasses and hearing care not included as a basic health care service.

(3) Dental services.

(4) Mental health services not included as a basic health care service.

(5) Long-term physical therapy and rehabilitative services.

(6) Cosmetic surgery, unless medically necessary.

(7) Prescribed drugs and medicines incidental to outpatient care. Supplemental coverage for prescription drugs shall also provide coverage of off-label uses of prescription drugs used in the treatment of cancer or the study of oncology. Coverage shall include the approval of oncology (chemotherapeutic) drugs for off-label indications when used for malignant disease, when the safety and effectiveness of use for this indication has been recommended, supported and demonstrated by at least one controlled clinical trial published in a nationally recognized peer reviewed journal or when at least one of the standard pharmacy compendia (United States Pharmacopoeia Dispensing Information [USPDI], American Society of Health-System Pharmacists Drug Information [AHFS Drug Information] or American Medical Association Drug Evaluations [AMADE]) lists the drug to be accepted as safe and effective for this indication. This will not include the off-label use of these agents in the treatment of non-malignant disease.

(8) Ambulance services, unless medically necessary.

(9) Care for military service connected disabilities for which the enrollee is legally entitled to services and for which facilities are reasonably available to this enrollee.

(10) Care for conditions that State or local law requires be treated in a public facility.

(11) Custodial or domiciliary care.

(12) Experimental medical, surgical, or other experimental health care procedures, unless approved as a basic health care service by the policy making body of the HMO.

(13) Personal or comfort items and private rooms, unless necessary during inpatient hospitalization.

(14) Whole blood and blood plasma.

(15) Durable medical equipment for home use (such as wheel chairs, surgical beds, respirators, dialysis and machines).

(16) Health care services which are unusual or infrequently provided and not necessary for the protection of individual health, as approved by the Department upon application by the HMO. "Unusual or infrequently used health services" means those health services which are projected to involve fewer that 1 percent (1%) of the encounters per year for the entire HMO enrollment, or, those health services the provision of which, given the enrollment projection of the HMO and generally accepted staffing patterns, is projected will require less than 0.25 full time equivalent health professionals.

Okla. Admin. Code § 365:40-5-21

Added at 21 Ok Reg 77, eff 11-1-03 (emergency); Added at 21 Ok Reg 1672, eff 7-14-04