Nonquantitative treatment limitations include:

1. (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. (2) Formulary design for prescription drugs;
3. (3) Standards for provider admission to participate in a network, including reimbursement rates;
4. (4) Plan methods for determining usual, customary, and reasonable charges;
5. (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. (6) Exclusions based on failure to complete a course of treatment;
7. (7) For plans with multiple network tiers, such as preferred providers and participating providers, network tier design; and
8. (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.

Source: 41 SDR 93, effective December 3, 2014.

General Authority: SDCL 58-17-87 , 58-18-79 , 58-18-79(15).

Law Implemented: SDCL 58-17-87 , 58-18-79 , 58-18-80.