NQTLs are processes, strategies, evidentiary standards, or other criteria that limit the scope or duration of benefits for services provided under the plan. Certain utilization reviews, prior authorization and plan provisions may only be applied to mental health/substance use disorder benefits if they are comparable to or less restrictive than those for medical surgical services.

NQTLs include, but are not limited to:

• Medical management standards limiting or excluding benefits based on medical necessity, medical appropriateness, or based on whether the treatment is experimental or investigative (including standards for concurrent review).
• Formulary design for prescription drugs.
• Network tier design.
• Fail-first policies or step therapy protocols. For example: Refusal to pay for higher-cost therapies until it can be shown that a lower-cost therapy is not effective.
• Exclusions based on failure to complete a course of treatment.
• 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.