Inflated insurance vs. self-pay drug prices used up my lifetime limit, any recourse? (NY)

Inflated insurance vs. self-pay drug prices used up my lifetime limit, any recourse? (NY)

I’m doing IVF in NY with a self-funded (i.e., not subject to NY IVF coverage mandates) employer plan administered by BCBS with Rx coverage administered by OptumRX. The Rx plan includes a $20K lifetime limit for infertility medications that must be purchased from Optum Specialty Pharmacy.

In my first cycle in May, I blew through nearly the entire $20K. Only later did I discover that the insurance price for the drugs was ~2.5x higher than the self-pay price. Had I self-paid at the in-network pharmacy and then submitted the claims for reimbursement, I would have used $7,592 vs. $19,798, allowing me funding for at least one more cycle.

Would OptumRx/Optum Specialty Pharmacy possibly allow me to change these already purchased and used medications to self-pay, fork over some money, and then submit the claims for reimbursement, recovering over half my lifetime limit, or should I just accept that I got screwed?

If it’s worth trying, where should I start, and whom from the company should I ask to speak with?
* OptumRX 
* Optum Specialty Pharmacy
* BCBS
* My employer’s HR office
* NY State Dept. of Financial Services (which handles health/prescription insurance complaints)

I did read about one patient who seemingly managed to pull this off in California, but not sure if it was just luck/persistence vs. something she was legally entitled to.

See also  Biosimilar Market Report