Clinical research study
The Consequences of Requesting “Dispense as Written”

https://doi.org/10.1016/j.amjmed.2010.11.020Get rights and content

Abstract

Background

All US states have adopted generic substitution laws to reduce medication costs. However, physicians may override these regulations by prescribing branded drugs and requesting that they are dispensed as written. Patients also can make these requests. Little is known about the frequency and correlates of dispense as written requests or their association with medication filling.

Methods

We identified beneficiaries of a large pharmacy benefits manager who submitted a prescription claim from any pharmacy in January 2009. We categorized claims as a physician-assigned dispense as written, patient-assigned dispense as written, or no dispense as written. We described rates of these requests and used generalized estimating equations to evaluate physician, patient, treatment, and pharmacy characteristics associated with dispense as written requests. We also used generalized estimating equations to assess the relationship between dispense as written designation and rates prescriptions are not filled by patients.

Results

Our sample included 5.6 million prescriptions for more than 2 million patients. More than 2.7% were designated as dispense as written by physicians, and 2.0% were designated as dispense as written by patients. Substantial variation in dispense as written requests were seen by medication class, patient and physician age, and geographic region. The odds of requesting dispense as written was 78.5% greater for specialists than generalists (P <;.001). When chronic prescriptions were initiated, physician dispense as written (odds ratio 1.50, P <;.001) and patient dispense as written (odds ratio 1.60, P <;.001) were associated with greater odds that patients did not fill the prescription.

Conclusion

Dispense as written requests were common and associated with decreased rates of prescription filling. Options to reduce rates of dispense as written requests may reduce costs and improve medication adherence.

Section snippets

Sample

We identified all patients enrolled in employer-sponsored health plans who received pharmacy benefits from CVS Caremark in calendar years 2008 and 2009. From this sampling frame, we selected all members with a) continuous eligibility for pharmacy benefits between July 1, 2008, and January 31, 2009, and b) a valid entry for gender and date of birth in the administrative record. We limited our sample to patients who submitted a prescription claim from any retail or mail-order pharmacy for

Results

We evaluated approximately 5.6 million prescriptions that were delivered to retail or mail-order pharmacies and adjudicated through Caremark during the 1-month period (Table 1). These prescriptions were written for 2,047,124 patients by 315,379 specialist physicians, 126,430 generalists, and 39,128 non-physician prescribers (eg, nurse practitioners). Patients and their insurance plans, respectively, paid an average of $17.90 and $26.67 for generic medications, $49.50 and $158.25 for

Discussion

In this national sample of prescriptions written for patients receiving drug coverage administered by a large pharmacy benefits manager, approximately 5% of all prescriptions included a dispense as written designation requesting dispensing of a brand product. Dispense as written requests were made by prescribers (2.7% of prescriptions) and patients (2.0% of prescriptions). Prescriptions written with dispense as written designations were more likely to be reversed, indicating that they were less

Study Limitations

Our study has limitations. We evaluated a commercially insured population; rates of dispense as written requests and prescription reversals may differ for uninsured patients. Our measure of reversal was linked to the specific prescription that was adjudicated by the pharmacy. Some of the unfilled prescriptions may not represent clinically significant medication non-adherence, because patients may have requested new prescriptions for different medications to treat the same condition. However,

Conclusions

Overall, we found that both patients and physicians commonly make dispense as written requests, totaling approximately 5% of all prescriptions. Advocates of dispense as written may argue that providing physicians and patients with greater discretion offers greater choice, opportunities for communication, and adherence to therapy. However, our results indicate that dispense as written requests are associated with excess costs, and that patients are less likely to fill prescriptions with dispense

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Funding: This work is supported by a research grant from CVS Caremark. Dr Shrank is supported by a career development award from the National Heart, Lung, and Blood Institute (HL-090505).

Conflict of Interest: JNL, AC, and TAB are employees of CVS Caremark, a company whose profits are related to medication choices. All other authors have no other conflicts to report.

Authorship: All authors had access to the data and played a role in writing this manuscript.

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