OptumRX dragging its heels correcting copay error—any recourse? (NY state)
My doctor prescribed a Tier 2 specialty drug last week. My employer’s OptumRx benefits summary makes clear that the copay for Tier 2 specialty drugs is the lesser of $45 or 25%; I have gotten many other expensive Tier 2 specialty drugs and seen this play out, always being charged $45 for them.
This time, the claim is coming out to the higher amount of 25%, about $361. After much arguing with lower-level representatives, I was able to get connected to a supervisor who saw the problem and filed a case report a few days ago.
(Note: My plan has no deductible—that’s not what’s going on here.)
The problem is, I have no faith that this case report is going to be resolved any time soon and I need this medication. It took over 3 hours and 13 different agents on the phone to get someone to even look up the case report in the system and say that someone would get to it. No one’s disputing that I’m being overcharged, but no one can tell me how or when it can be fixed.
It seems to be complicated by the fact that Optum owns the specialty pharmacy—my insurance hotline keeps sending me to the specialty pharmacy, who sends me right back to insurance, and I’m not sure if the same thing is happening with the case report. The different departments were arguing with each other and deflecting responsibility right in front of me.
Meanwhile, I can’t place the order with Optum Specialty Pharmacy without overpaying by over $300, and I absolutely need the drug by the end of next week. I could overpay and then get a refund, but I fear that’ll never happen given the incompetence and disregard I’ve seen so far.
Is there anything I can do about the fact that for the foreseeable future, they’re making me pay a lot of extra money for my medicine, with no promised resolution date? Should I give it X number of days and then seek help from the NY state insurance commissioner and/or my employer?
