48 Loy. U. Chi. L.J. 1041 (2016-2017)
Now or Never: The Urgent Need for Action against Unfair Coverage Denials for Quality Health Care

handle is hein.journals/luclj48 and id is 1087 raw text is: 







Now or Never: The Urgent Need for Action Against
   Unfair  Coverage Denials for Quality Health Care

     Stacey L. Worthy, Daniel C. McClughen, & Shruti Kulkarni*


INTRODUCTION           ...........................................1 042
I. COMMON  BENEFIT UTILIZATION MANAGEMENT   PRACTICES... 1044
      A. Step Therapy     ................................ 1044
          1. The ACA's Nondiscrimination Provision........... 1045
          2. The Medicaid Act: Reasonable Promptness
             Provision..................................... 1047
          3. State Claim Based on the Interference with the
             Physician-Patient Relationship ......  ....... 1048
      B. Adverse Tiering............................ 1051
          1. The ACA's Nondiscrimination and Preexisting
             Condition Provisions............      ......... 1053
          2. The Federal Rehabilitation Act .................. 1055
          3. State Claim Based on Unfair and Deceptive Trade
             Practices.............................1 057
      C. Nonmedical Switching    ................   ......1 059
          1. State Breach of Contract Claim................ 1060
          2. State Breach of Duty of Good Faith and Fair Dealing
             Claim............................... 1061
          3. State Claim Based on Unfair and Deceptive Trade
             Practices............................. 1062
      D. Prior Authorization  ............................ 1064
          1. The Medicaid Act's Payment for Covered Outpatient
             Drugs Provision   ..................   ...... 1066
          2. The Medicaid Act's Reasonable Promptness
             Provision..    ................................ 1068
          3. The Medicare Act's Part D Formulary
             Requirements     .....................  ....1 070
          4. State Claim Based on Unfair and Deceptive Trade

* Stacey L. Worthy is the Executive Director of the Alliance for the Adoption of Innovations in
Medicine (Aimed Alliance) and a partner at DCBA Law & Policy. Daniel C. McClughen and
Shruti R. Kulkarni are associate attorneys at DCBA Law & Policy.

                               1041

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