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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. 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 single-source brands, and $44.50 and $135.26 for multi-source brands.

Of the prescriptions we evaluated, 151,670 (2.7%) were designated as dispense as written by physicians and 112,243 (2.0%) were designated as dispense as written by patients. A majority of prescriptions designated as dispense as written by physicians were single-source brand products for which no generic alternatives were available. Most patient-assigned dispense as written prescriptions were for multi-source brands, which could have otherwise been substituted at the pharmacy without contacting the physician. Patient requests for dispense as written took place almost exclusively at retail pharmacies, whereas approximately one third of physician requests were filled at mail-order pharmacies.

Among multi-source brands used to treat chronic conditions (maintenance medications), patients failed to fill prescriptions more frequently when either patients or physicians requested dispense as written, compared with prescriptions with no dispense as written designation.

In multivariate analyses, older physicians were more likely to request dispense as written than younger ones, and patients age 55 to 74 years were most likely to receive physician dispense as written prescriptions. The odds of requesting dispense as written was 78.5% greater for specialists than generalists (P<;.001). Compared with rates of dispense as written request for oral antidiabetics (the referent class), a dispense as written was more likely to be written for anticonvulsants (odds ratio [OR] 2.2), estrogens (OR 2.2), migraine treatments (OR 2.4), thyroid medications (OR 9.8), and anticoagulants (OR 3.9). Physician dispense as written was more common in the northeast section of the country (OR 1.76 vs west, P<;.001) and when submitted to mail-order pharmacies.

The likelihood of patient dispense as written requests also varied by therapeutic class and region. Compared with oral antidiabetics, patient dispense as written requests were more common for ulcer agents (OR 6.1), hypnotics (OR 4.3), migraine medications (OR 14.4), contraceptives (OR 3.7), thyroid medications (OR 16.5), estrogens (OR 3.6), anticonvulsants (OR 4.8), anticoagulants (OR 4.5), and analgesics (OR 4.5). Patient dispense as written was requested most frequently in the west; there were 32.4% greater odds for having a patient-assigned dispense as written in the west than in the northeast (P<;.001). Dispense as written was most commonly requested by patients who were 55 to 74 years of age, for maintenance medications, and at retail pharmacies.

For each eligible prescription submitted, we constructed explanatory variables to assess the relationship between physician, patient, treatment, and pharmacy characteristics and dispense as written use and prescription filling. Physician variables included primary specialty, practice type (primary care, specialist, non-physician prescriber), and prescriber age. Patient characteristics included age (in years), gender, and US census region of residence. Treatment variables included the dispense as written assignment, GPI4/GPI2-designated therapeutic class, brand/generic status, and patient out-of-pocket cost (in dollars per 30-day equivalent prescription). Pharmacy characteristics included the type of dispensing pharmacy (retail or mail). Prescriptions were categorized as either acute or maintenance (chronic) using the First Data Bank designation. Maintenance medications were further categorized as either an “initiation” or “continuation” of therapy. Initiation prescriptions were defined on the basis of no paid pharmacy claims for a drug in the same therapeutic class in the 6 months before the index prescription claim. Maintenance continuation prescriptions were preceded by 1 or more paid claims in the previous 6 months, indicating recent use.
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Analysis Plan
We used descriptive statistics to evaluate patient, physician, pharmacy, and prescription characteristics. We described rates of dispense as written for both single-source brands and multi-source brands, despite the fact that dispense as written for single-source brands may not have any effect on prescription delivery. We also present rates of prescription reversals, prescription claims approved by a payer and then reversed by the pharmacy because they were not purchased by the patient and went unfilled, stratified by dispense as written designation and prescription type.

To assess the relationship between physician, patient, prescription, and pharmacy characteristics with physician and patient dispense as written requests, we used generalized estimating equations to adjust for clustering at the patient level. Our outcomes, at the submitted prescription level, were the presence or absence of physician dispense as written in one model and the presence or absence of patient dispense as written for the other. We studied whether physician, member, treatment, and pharmacy characteristics were associated with the submission of prescriptions with a dispense as written designation. When comparing rates of dispense as written requests by drug class, we selected oral diabetes medications as our referent category because they are essential medications, commonly prescribed, and include both generic and brand-name options.

Multivariate generalized estimating equation models were used to estimate the relationship between patient and physician dispense as written selection and whether the claim was reversed, indicating the medication was not purchased by the patient and went unfilled. In these models, we were interested in the relationship between dispense as written designation and rates of multi-source brand medication filling, because these are the medications for which dispense as written designations most clearly affect the medication received. Thus, in our primary model, we included only multi-source brand and generic medications. We ran a distinct model with single-source brands as a neutral control because we did not expect that dispense as written designation would have any effect on the medication that was delivered and, as a result, the likelihood of actual purchasing. In these models, we controlled for patient, physician, and pharmacy covariates and adjusted for clustering within patients. We included interactions between physician and patient dispense as written designations and prescription characteristics (initiation of a chronic medication, maintenance medication continuation, or acute medication), because we hypothesized that dispense as written designation may have the greatest effect on purchasing rates in new prescriptions or acute prescriptions, when patients first learn about the medication costs. Statistical evaluations were performed using SAS Version 9.1 with SAS/STAT(r) (SAS Institute Inc, Cary, NC) and Stata SE 9.1 for Windows (StataCorp LP, College Station, Tex).

Dispense as written requests may have important implications for patient adherence. Patients are more adherent when they are initiated on generic or lower-cost medications.9 Although dispense as written requests would seem to reflect a conscious decision by patients or their physicians to use a specific agent, the increased cost-sharing that results from a dispense as written designation may decrease the likelihood that patients actually fill their prescriptions.

Little is known about how frequently physicians or patients request dispense as written, the medications for which dispense as written is most commonly used, and the physician and patient characteristics associated with dispense as written requests. Previous descriptive analyses of this practice were conducted when generic use was far less common and have limited applicability to current practice.10, 11, 12 No prior studies have investigated the effect of dispense as written requests on patients’ likelihood to fill their prescriptions or on overall health system costs. By using transactional data from a large national pharmacy benefits manager, we assessed rates and correlates of dispense as written requests and the relationship between these requests and rates of filled prescriptions.

Materials and Methods

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 adjudication between January 1 and 31, 2009, the identification period. We excluded all clients who were enrolled in a plan that imposed penalties for dispense as written requests, because dispense as written requests in these settings may not reflect those in the general population.

For patients who submitted multiple eligible prescriptions within a class, we selected the prescription with the latest date during the identification period, which likely eliminates accidental or erroneous prescriptions that were delivered. If a member submitted prescriptions in multiple therapeutic classes, each was deemed eligible and included in the analysis. We included all therapeutic categories defined by MediSpan’s Generic Product Identifier (GPI-2).

We identified the dispense as written assignment and the brand status from the submitted claim record. We categorized claim records into 1 of 3 mutually exclusive categories: a physician-assigned dispense as written (Physician Dispense as Written); a member-assigned dispense as written (Patient Dispense as Written); or no Dispense as Written. Brands were listed as either single-source brand, indicating no generic equivalent was available at the time of the study, or multi-source brands, which are branded medications with a generic equivalent. For every eligible prescription, we also determined whether the prescription was purchased (“filled”) or reversed. Reversed prescriptions are those that the patient chose not to purchase, and therefore were not filled.