ARSD 20:06:58:24. Illustrative list of nonquantitative treatment limitations

Nonquantitative treatment limitations include: (1) Medical management standards limiting or excluding benefits based on medical necessity or medical appropriateness, or based on whether the treatment is experimental or investigative; (2) Formulary design for prescription drugs; (3) Standards for provider admission to participate in a network, including reimbursement rates; (4) Plan methods for determining usual, customary, and reasonable charges; (5) Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective, also known as fail-first policies or step therapy protocols; (6) Exclusions based on failure to complete a course of treatment; (7) For plans with multiple network tiers, such as preferred providers and participating providers, network tier design; and (8) Restrictions based on geographic location, facility type, provider specialty, and other criteria that limit the scope or duration of benefits for services provided under the plan or coverage.