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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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