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.

With the recent expansion of health insurance coverage to millions of Americans, there is increasing pressure to control health care costs. Greater use of generic medications has been identified as one approach to reduce medication costs without compromising quality. Studies do not suggest meaningful differences in clinical efficacy between brand-name and generic products. Yet generic medications remain underused when appropriate, and efforts to encourage their use can reduce both patient and health system costs.
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Every state has enacted generic substitution laws to promote generic drug use. However, both physicians and patients express concern about the safety and efficacy of generics. Physicians can ensure that a brand-name medication is delivered, even when a generic equivalent is available, by indicating “dispense as written” on their prescription. Similarly, patients can request that a brand be delivered rather than the generic equivalent at the point of purchase.