Clinical research studyThe Consequences of Requesting “Dispense as Written”
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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Cited by (37)
Influencers of generic drug utilization: A systematic review
2018, Research in Social and Administrative PharmacyCitation Excerpt :In addition, physicians can write prescriptions for brand-name drugs that are specifically marked “dispense as written”. Physicians and patients may direct pharmacists to dispense as written,90 or specifically request that pharmacists not fill with a generic equivalent,89 and these actions contribute to an estimated $1.2 billion in additional drug costs annually in the U.S.91 Through a systematic review of the literature, seven key domains of factors that influence generic drug use were identified.
BIOSIMILAR BIAS: A BARRIER TO ADDRESSING AMERICAN DRUG COSTS
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2022, ClinicoEconomics and Outcomes ResearchFactors Associated with Prescriptions for Branded Medications in the Medicare Part D Program
2021, JAMA Network OpenPatient factors associated with oral generic olanzapine initiation and substitution among Medicaid beneficiaries: a new user cohort study
2021, Current Medical Research and OpinionAssessment of Variation in State Regulation of Generic Drug and Interchangeable Biologic Substitutions
2021, JAMA Internal Medicine
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.