Do pharmacists get kickbacks for switching patients to generic drugs?

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Wallstreet said:
Interesting coming from someone who is NOT a clinician and does NOT even see patients!! What are you basing your psych experience and other experience on? You write for a pill and the doctor takes over. They tell you what to write, how to write it and you dispense it. That is where your job ends. What a joke. I do not tell you how to count out pills and put them in the bottle.
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Pharmacists don't see patients? What about ambulatory settings? Hospital? I think you have a narrow view of what a pharmacist does. Granted, Mikey has some strong opinions, but that doesn't mean you have to come on here and demean the profession.

There is more to pharmacy than counting pills and putting them in the bottle...

Where I work, pharmacists save the asses of many, many residents and doctors.

EDIT: And regarding psych, I know a few psychiatric pharmacists that would dance circles around many doctors when it comes to psychopharmacology knowledge.
 
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Wallstreet said:
Interesting coming from someone who is NOT a clinician and does NOT even see patients!! What are you basing your psych experience and other experience on? You write for a pill and the doctor takes over. They tell you what to write, how to write it and you dispense it. That is where your job ends. What a joke. I do not tell you how to count out pills and put them in the bottle.
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Are you implying the pharmacists are not the experts on drugs, but rather, the residents and medical clinicians would be? 😕

I'm pretty sure, in the 4 years required to get a PharmD, you learn more than counting pills by 5s.
 
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Wallstreet said:
Interesting coming from someone who is NOT a clinician and does NOT even see patients!! What are you basing your psych experience and other experience on? You write for a pill and the doctor takes over. They tell you what to write, how to write it and you dispense it. That is where your job ends. What a joke. I do not tell you how to count out pills and put them in the bottle.
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Yeah...I hate to break it to you, but I was a clinical pharmacist for a shade under two years recently and I did plenty of generic substituting. Specifically, I used to do warfarin monitoring and dosing in a hospital and saw no appreciable change in INR stable patients when we switched people from who knows what generic to the brand we stocked in the hospital. If that doesn't count as real world experience based on your stringent standards, I apologize.

Also, if you insist on harping about psychiatry, I said I can "kind of" see the issue with generic psych meds because the treatment is highly patient subjective and if they convince themselves that they are seeing more symptoms with a new generic, they will create a self-fulfilling "generics sucks" prophecy. This is a phenomenon I've seen myself, again, citing the Pfizer vs Greenstone generic scenario with Zoloft where the same ingredients and formulas, with product made in the same factory, apparently made some patients feel more depressed and that their meds "didn't work as well."

I'd love for you to explain to me how the Pfizer branded sertraline can outperform the Greenstone generic...I really would...
 
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Just received a fun e-mail today, generic Concerta is now available. You should be receiving your first shipment with your regular C-2 order. I can't wait to hear all the complaints.
 
Wallstreet said:
Interesting coming from someone who is NOT a clinician and does NOT even see patients!! What are you basing your psych experience and other experience on? You write for a pill and the doctor takes over. They tell you what to write, how to write it and you dispense it. That is where your job ends. What a joke. I do not tell you how to count out pills and put them in the bottle.
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disgusted.gif
 
museabuse said:
How is this different from any other state? In other states dont pharmacist usually dispense generic when the rx says Percocet without asking the pt?
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I don't know. You asked me what my state law says and I told you. I don't know the laws of other states.
 
Outcomes MTMs (getoutcomes.com) pay $20 for a successful switch from a branded drug to a generic alternative. Example: Lexapro --> citalopram
 
All4MyDaughter said:
Maybe I haven't seen that much b/c generic substitution is the legal default in this state. You come in with a script for Zocor - you get generic simvastatin. You come in with a script for Prinivil - it's lisinopril for you. Lopressor? Metoprolol tartrate. And so on... If *that's* all the metric is about, that's pretty boring. It should be an easy metric to meet, at least in this state.



I haven't seen programs like this in retail. But I've never worked for CVS. It makes sense from a business perspective I think. People are more likely to consistently fill meds that they can actually afford. Are stores evaluated on how effectively they can convert patients under this type of program?
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I didn't read this whole thing, you guys post too much too fast. Did anyone answer whether or not independent pharmacy owners make more money by switching their patients to generics? It makes sense to me, there's a higher profit margin.
 
owlegrad said:
We were taught the same for levo, never substitute one manufacturer for another, then you get out in practice and you find that patients frequently get whatever generic is available at the time. Preferred generic changes all the time, few patients are going to get the exact same manufacturer each time, doesn't seem to actually be a problem. :shrug:

Digoxin used to be an FL's negative formulary, not any more. I don't think levo ever was, I could be wrong though.
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I believe Levo used to be on there and was removed because all its formulations were A-rated (in the Orange book).
 
Sorry but a clinical pharmacist is not a clinician who makes any diagnosis or treatment plan. They simply implement the doctors plan. Managing INR is not being a clinician I am sorry. That is a pharmcist task of proper dosing etc. You do not start someone on coumadin, you follow the order.

For being a pharmacist some of you do not understand the basic laws that govern generic medication production. Maybe you should read up on this and it may explain to you why generics often do not work as well as their counterparts which are name brand.

To spell it out for you, generics need to meet certain criteria, none of which include similar efficacy. They require bioequivelence in regards to kinetics/dynamics BUT do you know the range they allow in the FDA? 80-125 percent within the range of the brand name. The average difference is about 3.5 percent which is very signifigant. However drugs that consistently do not work as well very likely have a great variablity in equivelence.

They also only require the same "active ingredients" which means the other ingredients can vary in chemistry. For example the salts of anions can vary, as well as various chemical bonds in the forumla as long as the "active" ingredients are similar. Again they only have to be within a range for active ingredient concentrations.

If you understood your field you would see as clear as day that with the acceptable ranges the FDA accepts and the literature showing average variations among generics, that it is completely likely that this difference often exists and explains why some are more similar than others based on these factors.
 
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Can the anion salts really be different between brand/manufacturer? So I can use whatever salt I want as long as bioavailability criteria are meet? I really don't think that is the case, but I am always open to learning new things.


They also only require the same "active ingredients" which means the other ingredients can vary in chemistry. For example the salts of anions can vary, as well as various chemical bonds in the formula as long as the "active" ingredients are similar. Again they only have to be within a range for active ingredient concentrations.
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Not similar, identical. Identical. No chemical bonds may be different between the active ingredient in a generic vs a branded product. Again if I am wrong, I would be happy to learn something new.
 
Wallstreet said:
Sorry but a clinical pharmacist is not a clinician who makes any diagnosis or treatment plan. They simply implement the doctors plan. Managing INR is not being a clinician I am sorry. That is a pharmcist task of proper dosing etc. You do not start someone on coumadin, you follow the order.

For being a pharmacist some of you do not understand the basic laws that govern generic medication production. Maybe you should read up on this and it may explain to you why generics often do not work as well as their counterparts which are name brand.

To spell it out for you, generics need to meet certain criteria, none of which include similar efficacy. They require bioequivelence in regards to kinetics/dynamics BUT do you know the range they allow in the FDA? 80-125 percent within the range of the brand name. The average difference is about 3.5 percent which is very signifigant. However drugs that consistently do not work as well very likely have a great variablity in equivelence.

They also only require the same "active ingredients" which means the other ingredients can vary in chemistry. For example the salts of anions can vary, as well as various chemical bonds in the forumla as long as the "active" ingredients are similar. Again they only have to be within a range for active ingredient concentrations.

If you understood your field you would see as clear as day that with the acceptable ranges the FDA accepts and the literature showing average variations among generics, that it is completely likely that this difference often exists and explains why some are more similar than others based on these factors.
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Thanks, I think we all know exactly what it is we do for a living. Just to play devil's advocate: if we're such useless, order-following monkeys, why do the vast majority of teaching hospitals have an ever-growing number of clinical pharmacists on staff? Surely, lofty institutions like the Mayo Clinic and Johns Hopkins couldn't possibly need the help of a pharmacist on rounds...wait, they do. Even during the weekends.

By the way, this paragraph is ridiculously wrong:

"They also only require the same "active ingredients" which means the other ingredients can vary in chemistry. For example the salts of anions can vary, as well as various chemical bonds in the forumla as long as the "active" ingredients are similar. Again they only have to be within a range for active ingredient concentrations."

Salts cannot vary, nor can "chemical bonds in the formula". Have you taken chemistry before? Those would both make it a different drug. I don't know where your idea of "similar" active ingredients came from, they're the "same" active ingredients.

You also mention a range and different percentages for bioequivalence. How do you think different product lots of a brand-name product are evaluated? Magic? Nope, it's the same tests as the generics.

Sheesh.
 
Wallstreet said:
Sorry but a clinical pharmacist is not a clinician who makes any diagnosis or treatment plan. They simply implement the doctors plan. Managing INR is not being a clinician I am sorry. That is a pharmcist task of proper dosing etc. You do not start someone on coumadin, you follow the order.

For being a pharmacist some of you do not understand the basic laws that govern generic medication production. Maybe you should read up on this and it may explain to you why generics often do not work as well as their counterparts which are name brand.
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Heads up: If you wouldn't say something in real life because it would sound rude or completely condescending, you might think twice about typing it on the internet.
 
Wallstreet said:
(verbal vomit)
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heh heh, it's like a corporate schill & lowly "i've got something to prove/MD is God" resident came together in this post.

hope your attending keeps you in line at work :meanie:
 
confettiflyer said:
heh heh, it's like a corporate schill & lowly "i've got something to prove/MD is God" resident came together in this post.

hope your attending keeps you in line at work :meanie:
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Though wallstreet is absolutely right about the efficacy part. Does anyone else think that its presumptuous to think bioavailability equals efficacy?

I think the Hatch-Waxman Act had much more of a economic and political agenda than patient welfare.

And what about surfactants, glidants, diluents, and all the other excipients? They may cause polymorphism and affect stability on top of the possible hypersensitivity.
 
drhenPharmD said:
Though wallstreet is absolutely right about the efficacy part. Does anyone else think that its presumptuous to think bioavailability equals efficacy?

I think the Hatch-Waxman Act had much more of a economic and political agenda than patient welfare.

And what about surfactants, glidants, diluents, and all the other excipients? They may cause polymorphism and affect stability on top of the possible hypersensitivity.
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No, that's why they do bioequivalence studies before the bioavailability studies. Those do mean efficacy.

And what the heck do you mean by polymorphism? That term, as far as I know, has no meaning outside of genetics. Don't disagree with the excipients, but hypersensitivity issues are excessively rare.
 
Praziquantel86 said:
No, that's why they do bioequivalence studies before the bioavailability studies. Those do mean efficacy.

And what the heck do you mean by polymorphism? That term, as far as I know, has no meaning outside of genetics. Don't disagree with the excipients, but hypersensitivity issues are excessively rare.
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👍

Thanks. You said it better and quicker than I could.
 
Praziquantel86 said:
No, that's why they do bioequivalence studies before the bioavailability studies. Those do mean efficacy.

And what the heck do you mean by polymorphism? That term, as far as I know, has no meaning outside of genetics. Don't disagree with the excipients, but hypersensitivity issues are excessively rare.
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Okay fine. Does anyone else think that we may not have all the facts to say bioequivalence and thus equal bioavailability means equal efficacy.

http://lmgtfy.com/?q=pharmaceutics+polymorphism
This is why Norvir had to be reformulated.
 
Praziquantel86 said:
No, that's why they do bioequivalence studies before the bioavailability studies. Those do mean efficacy.

And what the heck do you mean by polymorphism? That term, as far as I know, has no meaning outside of genetics. Don't disagree with the excipients, but hypersensitivity issues are excessively rare.
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Peesh. I am not impressed. So what if the ACTIVE ingredient must be chemically identical? So what if they must be bio-equivalent and have similar bioavailability? That doesn't mean the color of the dyes used is the same! :meanie:


On a more serious note, drug that are racemic mixtures - do the proportions have to be the same? Anyone know?
 
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drhenPharmD said:
Okay fine. Does anyone else think that we may not have all the facts to say bioequivalence and thus equal bioavailability means equal efficacy.

http://lmgtfy.com/?q=pharmaceutics+polymorphism
This is why Norvir had to be reformulated.
Click to expand...

Can excipients really affect polymorphism? If it does, I don't think it would qualify as a generic. If I am wrong, I would love to learn why.

Polymorphism is a term I heard in Med Chem. I never thought to learn what it meant, unitl now. :shrug:
 
owlegrad said:
Can excipients really affect polymorphism? If it does, I don't think it would qualify as a generic. If I am wrong, I would love to learn why.
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I still have a lot to learn, but I think that excipients can form polymorphic forms over time. To the best of my knowledge, this would go unnoticed as long as the ANDA only requires proof of bioequivalence and allows a much shorter drug approval timeline.

Owle, I hope you clicked on that google link.
 
drhenPharmD said:
I still have a lot to learn, but I think that excipients can form polymorphic forms over time. To the best of my knowledge, this would go unnoticed as long as the ANDA only requires proof of bioequivalence and allows a much shorter drug approval timeline.
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OK I am completely talking out of my *** here, but that sounds like a very theoretical concern, not something we actually observe. :shrug:

Well, I hate when wiki is my primary source, but yes I did. I was expecting a link to an article about Norvir, imagine my suprise when instead I got what I did. Rude, imo. 😆
 
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drhenPharmD said:
Okay fine. Does anyone else think that we may not have all the facts to say bioequivalence and thus equal bioavailability means equal efficacy.

http://lmgtfy.com/?q=pharmaceutics+polymorphism
This is why Norvir had to be reformulated.
Click to expand...

My apologies, I'd forgotten about that.

But yes, we do, via objective criteria. Unless you're arguing that drug concentration-time profiles that are statistically identical between branded and generic products are meaningless. If you'd like other studies, there are several conference abstracts examining patients switched from branded to generic products, using objective, in vivo data. The University of Pittsburgh put out one such example a year or two back regarding generic tacrolimus, although the name of the conference is escaping me right now.
 
Praziquantel86 said:
My apologies, I'd forgotten about that.

But yes, we do, via objective criteria. Unless you're arguing that drug concentration-time profiles that are statistically identical between branded and generic products are meaningless. If you'd like other studies, there are several conference abstracts examining patients switched from branded to generic products, using objective, in vivo data. The University of Pittsburgh put out one such example a year or two back regarding generic tacrolimus, although the name of the conference is escaping me right now.
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They most certainly are not meaningless.
 
MJayHart said:
Outcomes MTMs (getoutcomes.com) pay $20 for a successful switch from a branded drug to a generic alternative. Example: Lexapro --> citalopram
Click to expand...

They did a CE presentation in my city when the company first started. It was one of those really good ideas that just doesn't work.
 
Praziquantel86 said:
Thanks, I think we all know exactly what it is we do for a living. Just to play devil's advocate: if we're such useless, order-following monkeys, why do the vast majority of teaching hospitals have an ever-growing number of clinical pharmacists on staff? Surely, lofty institutions like the Mayo Clinic and Johns Hopkins couldn't possibly need the help of a pharmacist on rounds...wait, they do. Even during the weekends.

By the way, this paragraph is ridiculously wrong:

"They also only require the same "active ingredients" which means the other ingredients can vary in chemistry. For example the salts of anions can vary, as well as various chemical bonds in the forumla as long as the "active" ingredients are similar. Again they only have to be within a range for active ingredient concentrations."

Salts cannot vary, nor can "chemical bonds in the formula". Have you taken chemistry before? Those would both make it a different drug. I don't know where your idea of "similar" active ingredients came from, they're the "same" active ingredients.

You also mention a range and different percentages for bioequivalence. How do you think different product lots of a brand-name product are evaluated? Magic? Nope, it's the same tests as the generics.

Sheesh.
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Wow you are Slow. Changing a cation/anion does not make it a different active drug-you can put a number of -/+ molecules to pair with an active charged molecule. Cerfuroxime sodium and cefuroxime axetil is one of many examples, or hydroxyzine pamoate v. hydroxyzine HCL. Active ingredient is unchanged but the salt is. Same goes for forms of valproic acid on and on. Sad I know more pharm than a pharmacist and that is ALL you have to know :soexcited:

Sorry different lots of "brand names" do not vary by 80-125 percent as they are the same exact ingredients whereas generics are not. You are embarrasing yourself! 🤣

Oh yes, the only reason insitues have you guys is politcs.
 
Wallstreet said:
Wow you are Slow. Changing a cation/anion does not make it a different active drug-you can put a number of -/+ molecules to pair with an active charged molecule. Cerfuroxime sodium and cefuroxime axetil is one of many examples, or hydroxyzine pamoate v. hydroxyzine HCL. Active ingredient is unchanged but the salt is. Same goes for forms of valproic acid on and on. Sad I know more pharm than a pharmacist and that is ALL you have to know :soexcited:

Oh yes, the only reason insitues have you guys is politcs.
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I realize that different salt forms exist and are independently marketed. Your examples don't prove your point. Hydroxyzine HCl is a generic for Atarax while hydroxyzine pamoate is a generic for Vistaril. Maybe the reason your patients do poorly on generics is that you give them the WRONG DRUG. You do realize that the salt form alters release characteristics, right?

And tell me what the politics of improved patient outcomes is. I'd like to know.
 
Wallstreet said:
Wow you are Slow. Changing a cation/anion does not make it a different active drug-you can put a number of -/+ molecules to pair with an active charged molecule. Cerfuroxime sodium and cefuroxime axetil is one of many examples, or hydroxyzine pamoate v. hydroxyzine HCL. Active ingredient is unchanged but the salt is. Same goes for forms of valproic acid on and on. Sad I know more pharm than a pharmacist and that is ALL you have to know :soexcited:

Sorry different lots of "brand names" do not vary by 80-125 percent as they are the same exact ingredients whereas generics are not. You are embarrasing yourself! 🤣

Oh yes, the only reason insitues have you guys is politcs.
Click to expand...

I am a P1 and I know mountains more pharm than you...
 
Wallstreet said:
Wow you are Slow. Changing a cation/anion does not make it a different active drug-you can put a number of -/+ molecules to pair with an active charged molecule. Cerfuroxime sodium and cefuroxime axetil is one of many examples, or hydroxyzine pamoate v. hydroxyzine HCL. Active ingredient is unchanged but the salt is. Same goes for forms of valproic acid on and on.
Click to expand...

You can't possible believe that one of those is the generic form of the brand named product? Different salt form = different drug product. Metoprolol succinate is not the generic form of Lopressor (for instance).
 
Wallstreet said:
Wow you are Slow. Changing a cation/anion does not make it a different active drug-you can put a number of -/+ molecules to pair with an active charged molecule. Cerfuroxime sodium and cefuroxime axetil is one of many examples, or hydroxyzine pamoate v. hydroxyzine HCL. Active ingredient is unchanged but the salt is. Same goes for forms of valproic acid on and on. Sad I know more pharm than a pharmacist and that is ALL you have to know :soexcited:

Sorry different lots of "brand names" do not vary by 80-125 percent as they are the same exact ingredients whereas generics are not. You are embarrasing yourself! 🤣

Oh yes, the only reason insitues have you guys is politcs.
Click to expand...

lol...the more he types, the funnier this gets. hahaha
 
Wow you pill counters really stick together even when you are all wrong. Sorry but 99 percent of pharmcologists are useless. This is common discussion among physicians and we question why these centers are paying all these people to look on their palm pilot to tell us things we already know-that is called politics. That is also why your job market sucks because electronic data bases is completely replacing you guys. Once they can get a consistent machine to sit in wallgreens to count out pills and stick them in a bottle you guys are really SOL:laugh:
 
Praziquantel86 said:
Since you added that after the fact, what exactly do you think varies 80 - 125%? I'm curious to know.
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After what fact-its in my post way above. Its the bioavailability variance accepted by the fda. Its on the fda site! Go do some reading!!
 
Wallstreet said:
Wow you pill counters really stick together even when you are all wrong. Sorry but 99 percent of pharmcologists are useless. This is common discussion among physicians and we question why these centers are paying all these people to look on their palm pilot to tell us things we already know-that is called politics. That is also why your job market sucks because electronic data bases is completely replacing you guys. Once they can get a consistent machine to sit in wallgreens to count out pills and stick them in a bottle you guys are really SOL:laugh:
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How did you get so far in life with an attitude like this?
 
Praziquantel86 said:
My apologies, I'd forgotten about that.

But yes, we do, via objective criteria. Unless you're arguing that drug concentration-time profiles that are statistically identical between branded and generic products are meaningless. If you'd like other studies, there are several conference abstracts examining patients switched from branded to generic products, using objective, in vivo data. The University of Pittsburgh put out one such example a year or two back regarding generic tacrolimus, although the name of the conference is escaping me right now.
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Thank you Dr. Hen-finally someone with reason. Maybe now you all will concede
 
Praziquantel86 said:
You did see me quoting you before you added that part, right?
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Dude I have no clue what you are saying READ fda.gov. Its taken directly from there. What else do I have to say. I read and I posted the data. GO read before you post again. Just like you were so quick to post above until your colleague pointed out to you that you were mistaken. Then you said "oh i forgot" Because you post faster than you can think
 
Wallstreet said:
Attitude started with your colleagues my friend. Read all their condescending posts before you comment
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I've read it. WVU thinks some MDs don't make wise drug choices all of the time. That doesn't seem condescending.

Are you certain all MDs always provide the best drug choice for the patient? I think that would be a hard statement to support.

You then made rude comments regarding pharmacists in general, insinuating they know nothing about drugs. You went on to insult the intelligence of others. When I read it, you sound condescending; the others sound like they're backing each other up.
 
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Wallstreet said:
The average difference is about 3.5 percent which is very signifigant. However drugs that consistently do not work as well very likely have a great variablity in equivelence.
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Actually 3.5% is great. That is within the range that different batches of the same brand name drug is allowed.

--------------------------------
But let's clear something up. There appears to be huge misconceptions about this issue from everyone in this thread. Brand-generic substitution is not something that is done willy-nilly. Brand-generic allowances are very state specific.

USG0801-GENSub-Law-T2.jpg


* One might notice that generic substitution is actually mandatory in some states if DAW is not indicated
* The majority of states (30+) require the use of the Orange Book to make brand-generic substitutions, which though rough as it is, has greater guidance regarding therapeutic equivalence not just bioequivalence.
* Additional restrictions and guidance obviously exist per state depending on whether there is a positive/negative formulary, NTI drug specific rules, etc.
--------------------------------

But sheesh, this thread is going down the drain.
 
Wallstreet said:
Once they can get a consistent machine to sit in wallgreens to count out pills and stick them in a bottle you guys are really SOL:laugh:
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Yeah, and believe me, Walgreens knows that. It's also the only correct thing you've said in this thread.

:whoa: :beat:
 
drhenPharmD said:
Owle, I hope you clicked on that google link.
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I forgot to say earlier, thank you for getting my name right! And thanks for the link, I guess. 😉

owlegrad said:
On a more serious note, drug that are racemic mixtures - do the proportions have to be the same? Anyone know?
Click to expand...

So no one knows? Or they just don't want to share? It's summertime guys, I promise it's not homework help! :meanie:
 
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