Certain health care services are not covered in the Insure Oklahoma/O-EPIC IP benefit package listed in OAC 317:45-11-10. These services include, but are not limited to:
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(1) services that the member's PCP or Insure Oklahoma/O-EPIC does not consider medically necessary;
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(2) any medical service when the member refuses to authorize release of information needed to make a medical decision;
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(3) organ and tissue transplant services;
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(4) weight loss intervention and treatment including, but not limited to, bariatric surgical procedures or any other weight loss surgery or procedure, drugs used primarily for the treatment of weight loss including appetite suppressants and supplements, and/or nutritional services prescribed only for the treatment of weight loss;
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(5) procedures, services and supplies related to sex transformation;
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(6) supportive devices for the feet (orthotics) except for the diagnosis of diabetes;
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(7) cosmetic surgery, except as medically necessary and as covered in
OAC 317:30-3-59(19);
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(8) over-the-counter drugs, medicines and supplies except contraceptive devices and products, and diabetic supplies;
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(9) experimental procedures, drugs or treatments;
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(10) dental services (preventive, basic, major, orthodontia, extractions or services related to dental accident) except for pregnant women and as covered in
OAC 317:30-5-696;
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(11) vision care and services (including glasses), except services treating diseases or injuries to the eye;
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(12) physical medicine including chiropractic, acupuncture and osteopathic manipulation therapy;
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(13) hearing services;
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(14) transportation [emergent or non-emergent (air or ground)];
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(15) rehabilitation (inpatient);
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(16) cardiac rehabilitation;
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(17) allergy testing and treatment;
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(18) home health care with the exception of medications, intravenous (IV) therapy, supplies;
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(19) hospice regardless of location;
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(20) Temporomandibular Joint Dysfunction (TMD) (TMJ);
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(21) genetic counseling;
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(22) fertility evaluation/treatment/and services;
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(23) sterilization reversal;
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(24) Christian Science Nurse;
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(25) Christian Science Practitioner;
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(26) skilled nursing facility;
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(27) long-term care;
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(28) stand by services;
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(29) thermograms;
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(31) services of a Lactation Consultant;
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(32) services of a Maternal and Infant Health Licensed Clinical Social Worker; and
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(33) enhanced services for medically high risk pregnancies as found in
OAC 317:30-5-22.1.