Common use of Eligible Institutions Clause in Contracts

Eligible Institutions. The SELECT Plan only covers services or supplies provided by a legally operated Hospital, Medicare- approved Skilled Nursing Facility or other properly licensed facility specified as covered in this Evidence of Coverage. Any institution that is primarily a place for the aged, a nursing home or a similar institution, regardless of how it is designated, is not an eligible institution. Services or supplies that are provided by such institutions are not covered. Medical equipment and supplies (including insulin), that are available without a prescription, are covered when prescribed by a Physician for the management and treatment of diabetes, or for preventive purposes in accordance with the U.S. Preventive Services Task Force A and B recommendations or for female contra- ception as approved by the FDA. Any other Nonprescription drug, medical equipment or supply that can be purchased without a Prescription Drug Order is not covered, even if a Physician writes a Prescription Drug Order for such drug, equipment or supply unless listed in the Recommended Drug List. However, if a higher dosage form of a nonprescription drug or over-the-counter drug is only available by prescription, that higher dosage drug may be covered when Medically Necessary. If a drug that was previously available by prescription becomes available in an over-the-counter (OTC) form in the same prescription strength, then Prescription Drugs that are similar agents and have comparable clinical effect(s) will only be covered when Prior Authorization is obtained from Health Net. Services that do not meet national standards for professional medical or mental health practice, including, but not limited to, ▇▇▇▇▇▇/The Forum, primal therapy, bioenergetic therapy, hypnotherapy and crystal healing therapy are not covered. For information regarding requesting an Independent Medical Review of a denial of coverage see the “Independent Medical Review of Investigational or Experimental Therapies” portion of the “General Provi- sions.” The SELECT Plan does not cover personal or comfort items. The SELECT Plan does not cover Physician self-treatment rendered in a non-emergency (including, but not limited to, prescribed services, supplies and drugs). Physician self-treatment occurs when Physicians provide their own medical services, including prescribing their own medication ordering their own laboratory tests and self-referring for their own services. Claims for emergency self-treatment are subject to review by Health Net.