NOEL KING, HOST:
NPR and Kaiser Health News have been looking over your medical bills each month, and we've seen some pretty outrageous charges. You might remember the $28,000 throat swab that we told you about. NPR's pharmaceuticals correspondent, Sydney Lupkin, is here to talk about the latest. Hey, Sydney. How are you?
SYDNEY LUPKIN, BYLINE: Hi, Noel.
KING: So what's going on this month?
LUPKIN: Well, this month involves a young girl who needed a very expensive medication, but doctors told her father there was a cheaper drug that was almost exactly the same.
KING: That sounds great. Cheaper drug, cheaper option is good.
LUPKIN: Well, it would be. But the insurance company told the hospital it wouldn't cover the cheaper drug. And the more expensive one was going to cost a lot more.
KING: But for the same medication.
LUPKIN: Virtually the same. They are two nearly identical drugs made by the same company. But they are tens of thousands of dollars apart in price. So I went to Portland, Ore., to meet this family and find out more.
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SUDEEP TAKSALI: Hello. Hi.
LUPKIN: I'm Sydney. Nice to meet you.
TAKSALI: Hi, Sydney. Nice to meet you. Welcome.
LUPKIN: This is Sudeep Taksali, an orthopedic surgeon. He's also a dad.
TAKSALI: We adopted our daughter about two years ago from India.
LUPKIN: And you adopted her when she was how old?
TAKSALI: She was 6 when we got her.
LUPKIN: She's 8 now and a big reader.
UNIDENTIFIED CHILD: Six.
LUPKIN: Six? Six books that you're reading?
UNIDENTIFIED CHILD: Yeah. Three here and three at school. This one is about Ramona, who's kind of crazy.
LUPKIN: We're not naming her to protect her medical privacy.
TAKSALI: What other books are you reading?
UNIDENTIFIED CHILD: "Dear Napoleon, I Know You're Dead, But..."
TAKSALI: That's an interesting title. What's that book about?
UNIDENTIFIED CHILD: It's about a boy named Marnie.
TAKSALI: I would've thought it was about a boy named Napoleon.
UNIDENTIFIED CHILD: He's dead.
LUPKIN: Over this past summer, her parents noticed that she had gotten very tall for her age - taller than their 12-year-old son. Doctors eventually diagnosed her with a rare condition, central precocious puberty. It meant that she would go through sexual development much earlier than her peers.
TAKSALI: The poor girl's, like, been through a lot - all these transitions and adjusting to a new country, new language, new family, of course.
LUPKIN: They didn't want early puberty to be one more obstacle for her. Doctors told them there is a way to pause her puberty. It's a little implant that goes under the skin in her arm and releases a drug called histrelin acetate. It's a hormone blocker. There are two versions made by the same company, Endo Pharmaceuticals. One is called Supprelin LA. It was approved for central precocious puberty. And the company charges hospitals about $37,000 for it. It lasts for a year or two. The other is called Vantas, and it was approved to treat prostate cancer. Endo priced this one at about 4 1/2 thousand dollars.
TAKSALI: They're the same drug made by the same pharmaceutical company with a very trivial difference in dosing.
LUPKIN: The Taksalis' insurance, UnitedHealthcare, would only cover the expensive one, Supprelin. Sudeep wanted to know what that was going to cost them because hospitals add markups. He wasn't expecting what someone finally told him - $95,000.
TAKSALI: I was scared when I heard that number, and I was angry about this disparity.
KING: So what did you find out about the extreme disparity in cost? Why does one of these drugs cost so much more than the other when they're basically the same thing?
LUPKIN: So I asked Endo Pharmaceuticals, which makes both of these drugs, that exact question. And I didn't come away feeling like I understood why they priced the drugs so differently. They just said it was approved as two different products to treat two different patient populations. When I followed up with Endo to ask whether one was somehow more expensive to manufacture, they didn't answer. They just sort of stressed that these are not identical. And that's true. There is a tiny dosing difference. It's 15 micrograms, which is less than the weight of an eyelash. But I talked to several doctors who say that, clinically, it doesn't really make a difference for children who have this condition.
KING: So why did the Taksalis' health care company, UnitedHealthcare, say no to the cheaper option?
LUPKIN: So their policy is not to cover Vantas for this early puberty condition because it isn't approved by the FDA for that. Remember, Vantas is only approved to treat prostate cancer. So I asked the FDA, why was this drug approved as two distinct products when they're so similar? And they said it was up to the company to submit the application the way that they wanted to.
KING: So what ended up happening to Sudeep and his daughter?
LUPKIN: So a few days before the procedure, Sudeep told the hospital that a reporter was looking into this. Our partners at Kaiser Health News had called them. Soon after, the hospital submitted its request for Vantas again, this time citing cost as an issue. And it was approved. Then she got the implant. Here's her dad again.
TAKSALI: The doctor wanted to talk to her about the implant and the procedure and puberty. She brought up periods. And she's like, do you know what a period is? And she's like, yeah, it goes at the end of a sentence.
KING: Oh, my goodness. So how much are her parents going to end up paying?
LUPKIN: They got one of those explanation of benefits, which are sort of like a pre bill that your insurance company sends you. That's an estimate of how much you might be on the hook for. And the hospital still charged triple the price for Vantas. It came in at more than $12,000 dollars and Sudeep was responsible for about $4,700 of that after insurance.
KING: OK, so it could've been worse, but it's still a lot of money.
LUPKIN: The irony is all this hard work to get the drug switched probably won't wind up saving him that much money because he had a high-deductible plan. He did sort of a back-of-the-envelope calculation to try to figure it all out.
TAKSALI: To me one of the most mind-blowing things about this whole story - UnitedHealthcare saved approximately $45,000 from all these efforts. And I may save a couple hundred bucks.
KING: OK, so let me ask you what we always ask in these segments. If this happens to someone out there listening, what should they do?
LUPKIN: If you get prescribed a really expensive drug. The first thing you can do is ask questions. Ask your doctor. Ask your pharmacist. Are there cheaper options? You can also do a little online sleuthing - GoodRx and drugs.com can help you compare costs. If you get an insurance denial, you can appeal it, though it is tricky. Sudeep said he got the fastest, most consistent responses by direct messaging UnitedHealthcare on Twitter, even though he's not really a Twitter celebrity. He has fewer than 100 followers. And you can, of course, always negotiate even after you get your bill.
KING: Thank you, Sydney.
LUPKIN: You bet.
KING: Sydney Lupkin is NPR's pharmaceuticals correspondent. And remember, folks, if you have a surprising or unexpected or outrageous medical bill that you want us to take a look at, go to NPR's Shots blog and tell us all about it.
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