Do pharmacists get kickbacks for switching patients to generic drugs?

[All4MyDaughter]

There is an interesting thread in the Topics in Healthcare forum on SDN about pharmaceutical companies. I raised the issue of samples and my belief that they often interfere with evidence based prescribed. Plus the burden of pharmacists having to get patients switched to generics after samples run out, etc. etc. Bah. I don't like samples.

Someone replied and said that pharmacists get kickbacks for switching patients to generics. I have personally *never* seen this, but maybe I'm sheltered?

I've worked a number of different places and never heard tale of an incentive program to switch patients to generics. What I *have* seen - MANY - times are contests and other incentives to get people to try new brand name drugs. My very first exposure was over 5 years ago when there was a contest at my employer (sponsored by a drug company) encouraging pharmacists to get patients to switch from other PPIs to Aciphex.

If these "Generic Switch" incentives exist, who pays them? Generic drug companies? Insurance companies? Who are they paid TO? I kind of doubt they go to individual pharmacists, since the majority of them don't own the pharmacies.

I'm interested to see if anyone has ever heard of this?

Original thread: http://forums.studentdoctor.net/showthread.php?p=10930026#post10930026

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[Praziquantel86]

I don't think it's a "kickback" so much as increased profit. Doctor M can probably speak to this better than I can, but the margins are incredibly better on generic drugs. Kickback to me has this awful moral connotation that makes it seem like a bad thing.

If it were a cardiologist switching to Johnson+Johnson stents instead of Medtronic because they put him on their speakers bureau, that's a kickback. If he switches because they're cheaper, that's smart practice. Big difference.

 

[owlegrad]

The only thing close to that that I know of is generic conversion rates that are tracked by every major chain and a pharmacist's bonus can be partly tied to it as one of many factors. Generics are more profitable for pharmacies, so they want you to dispense as many as possible.

I know of no kickback system for pharmacist to do that. I think that poster is talking about generic conversion rate-based bonuses. Nothing else makes sense.

 

[All4MyDaughter]

The only thing close to that that I know of is generic conversion rates that are tracked by every major chain and a pharmacist's bonus can be partly tied to it as one of many factors. Generics are more profitable for pharmacies, so they want you to dispense as many as possible.

I know of no kickback system for pharmacist to do that. I think that poster is talking about generic conversion rate-based bonuses. Nothing else makes sense.

Yeah but that's not a *kickback* is it? It's something your employer is expecting you to do.

Admittedly, it's been a long time since I worked retail regularly. But I am confident that I've never been told to call and get a patient switched because "it's profitable for the pharmacy." The reasons I've seen are always: 1) Medicaid doesn't pay for brand 2) Patient pays cash and said HELL NO to $150/month and/or 3) Patient demands lower copay alternative.

 

[owlegrad]

Yeah but that's not a *kickback* is it? It's something your employer is expecting you to do.

Admittedly, it's been a long time since I worked retail regularly. But I am confident that I've never been told to call and get a patient switched because "it's profitable for the pharmacy." The reasons I've seen are always: 1) Medicaid doesn't pay for brand 2) Patient pays cash and said HELL NO to $150/month and/or 3) Patient demands lower copay alternative.

I know he said "speaking of kickbacks", but I really think he just meant "bonus". No kickback system exists that I know of. How often did you dispense a brand product when a generic was available? Not often, I would be willing to bet.

 

[All4MyDaughter]

I know he said "speaking of kickbacks", but I really think he just meant "bonus". No kickback system exists that I know of. How often did you dispense a brand product when a generic was available? Not often, I would be willing to bet.

At my first pharmacy job there was a niche of customers who ALWAYS got brand. But that pharmacy was in the highest SES zip code in the city. At subsequent jobs? Hardly ever.

Of course, generic substitution is the law in this state.

How many times have I called a physician to switch a patient to a generic alternative when either they couldn't or wouldn't pay for brand or when insurance rejected brand or assigned it to a higher copay tier? TONS.

Examples (these are just the common ones I remember from the last year):

Lexapro --> citalopram
Pristiq --> venlafaxine
Any name brand ARB --> ACEI (in newly diagnosed patients anyway)
Aciphex, Kapidex, Nexium --> omeprazole
Oracea --> regular doxy 50 mg

 

[Praziquantel86]

Honestly, the only thing I can think of that I wouldn't feel 100% comfortable switching to the generic is phenytoin. Not that there's inherently any difference in brand/generic, but the absorption issues with the different formulations are significant enough to make me think there might be a difficulty changing.

Everything else that people commonly mention, including warfarin, levothyroxine, tacrolimus, CsA, just strikes me as ridiculous. They're monitored so frequently and so variable within a patient that any difference is more likely due to timing of the dose than the drug itself.

After I write this, I'm not entirely sure it's relevant. Oh well.

 

[All4MyDaughter]

Honestly, the only thing I can think of that I wouldn't feel 100% comfortable switching to the generic is phenytoin. Not that there's inherently any difference in brand/generic, but the absorption issues with the different formulations are significant enough to make me think there might be a difficulty changing.

Everything else that people commonly mention, including warfarin, levothyroxine, tacrolimus, CsA, just strikes me as ridiculous. They're monitored so frequently and so variable within a patient that any difference is more likely due to timing of the dose than the drug itself.

After I write this, I'm not entirely sure it's relevant. Oh well.

I think it's relevant. When I started out in this field I was told to NEVER EVER NEVER EVER switch patients who were on thyroid products. But after seeing a bunch of rejects for name brand Synthroid, I quickly realized that there is not much harm in switching a patient from Synthroid --> generic on their FIRST fill. I mean, what's the harm? They get stabilized on whatever product they start out on. I have seen pharmacists who won't do it though. It used to be prohibited in this state but it's not anymore.

 

[owlegrad]

I think it's relevant. When I started out in this field I was told to NEVER EVER NEVER EVER switch patients who were on thyroid products. But after seeing a bunch of rejects for name brand Synthroid, I quickly realized that there is not much harm in switching a patient from Synthroid --> generic on their FIRST fill. I mean, what's the harm? They get stabilized on whatever product they start out on. I have seen pharmacists who won't do it though. It used to be prohibited in this state but it's not anymore.

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.

Digoxin used to be an FL's negative formulary, not any more. I don't think levo ever was, I could be wrong though.

 

[confettiflyer]

The only experience I've seen is increased profit for the pharmacy and a pat on the back for the pharmacist as it was a metric that was looked at extensively.

It's no different than any other product/company. There were contests at CVS for associates to sell generic lip balm. I used to work for a bookstore and we were told that if a customer wanted a classic book (anything where the copyright expired)...steer them to the "bargains" section where our in-house publisher had a $4 version vs. a $12.95 "big publisher" copy. Win-win.

but yeah sounds like that guy was talking out of his ass for the kickback thing, incentive is the better word.

 

[All4MyDaughter]

Retail peeps - do you actively try to get people switched to meet that metric? I've never seen that happen. But maybe I've never worked for a chain that tracked that.

 

[rph3664]

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.

Digoxin used to be an FL's negative formulary, not any more. I don't think levo ever was, I could be wrong though.

The one drug I've seen that had a generic that was almost consistently preferred was amantadine. Several people told me that they had tried the yellow capsules, and the red capsules, and one color (I can't remember which right now) worked much, much better than the other for their Parkinson's. I have no idea if this was also true when it was used for influenza A.

I also once had a customer with RA who needed a certain generic methotrexate tablet because she discovered that it was the only one that didn't make her sick.

I don't have a problem with samples when they're used for something that is short-term (i.e. antibiotics) or if the doctor wants to make sure a patient can tolerate a med before they fill an RX for an expensive drug that they can't tolerate, or might not work.

 

[All4MyDaughter]

Patients around here only want the "Blue Watsons" but that's not the kind of generic substitution issue I'm talking about.

 

[confettiflyer]

Retail peeps - do you actively try to get people switched to meet that metric? I've never seen that happen. But maybe I've never worked for a chain that tracked that.

Back in my retail days, I would switch people to generics because it was cheaper for them, not because of any stupid company metric. For once, these goals were aligned.

It would actually be a pain in the ass to get someone on brand of anything. I would type in the brand and it would automatically get converted to generic upon input. I would have to manually go in, retype the brand, and give a reason why (eg physician's request, patient request, generic out of stock, etc...).

So 3 things: cheaper for patient, easier on my workflow, better metrics (in order of importance).

 

[All4MyDaughter]

Back in my retail days, I would switch people to generics because it was cheaper for them, not because of any stupid company metric. For once, these goals were aligned.

It would actually be a pain in the ass to get someone on brand of anything. I would type in the brand and it would automatically get converted to generic upon input. I would have to manually go in, retype the brand, and give a reason why (eg physician's request, patient request, generic out of stock, etc...).

So 3 things: cheaper for patient, easier on my workflow, better metrics (in order of importance).

Yeah, in my experience the main impetus for switching a patient to a generic drug was patient request/demand.

And I don't mean generic substition. I mean "Doctor wrote for Lipitor. Copay is ONE MILLION DOLLARS. Can we switch to generic simvastatin?"

 

[owlegrad]

Retail peeps - do you actively try to get people switched to meet that metric? I've never seen that happen. But maybe I've never worked for a chain that tracked that.

Oh God yes, at least at my store. I think you may be getting the wrong idea though - the goal is to get people to fill generic when a generic is available. If no generic is available, your metric will not be hurt. At least that is how it was explained to me at CVS.

As you know, it is the insurance companies that "incentivize" patients to switch meds when no generic is available. But even CVS tries to get people to switch to cheaper meds when they can - it's really win-win for everyone. The best example I can think of right now is patients on Vytorin are educated about the possibility of being well controlled on simvastatin alone. Would you like us to call your doctor and ask him to consider changing you to simvastatin for a trial period to evaluate effectiveness? BTW, you will save 50/month on your copay. I am 100% for steering patients to a low cost, effective alternative whenever possible. There is no reason to reward drug companies for making me two drugs whose only contribution is to the bottom line.

 

[owlegrad]

Yeah, in my experience the main impetus for switching a patient to a generic drug was patient request/demand.

And I don't mean generic substition. I mean "Doctor wrote for Lipitor. Copay is ONE MILLION DOLLARS. Can we switch to generic simvastatin?"

One of very few issues I agree with insurance companies about. There is no need to start patients on the most expensive drug in it's category.

 

[All4MyDaughter]

Oh God yes, at least at my store. I think you may be getting the wrong idea though - the goal is to get people to fill generic when a generic is available. If no generic is available, your metric will not be hurt. At least that is how it was explained to me at CVS.

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.

As you know, it is the insurance companies that "incentivize" patients to switch meds when no generic is available. But even CVS tries to get people to switch to cheaper meds when they can - it's really win-win for everyone. The best example I can think of right now is patients on Vytorin are educated about the possibility of being well controlled on simvastatin alone. Would you like us to call your doctor and ask him to consider changing you to simvastatin for a trial period to evaluate effectiveness? BTW, you will save 50/month on your copay. I am 100% for steering patients to a low cost, effective alternative whenever possible. There is no reason to reward drug companies for making me two drugs whose only contribution is to the bottom line.

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?

 

[All4MyDaughter]

One of very few issues I agree with insurance companies about. There is no need to start patients on the most expensive drug in it's category.

Exactly! And that's precisely what I think samples encourage prescribers to do. What is the point of samples if it's not to encourage prescribers to write full scripts for those meds? Drug companies aren't giving away samples to "help the poor" or to save patients money.

I was trying different migraine meds and got samples for a specific brand. It worked ok so I tried to fill the full script. Insurance rejection city!!! Got some generic sumatriptan and it worked just fine. As well as the pricey brand anyway.

My podiatrist gave me samples for Zipsor... a fancy new NSAID. Wasn't any more effective for my pain than ibuprofen or naproxen. Didn't even try to fill that script b/c what was the point?

 

[owlegrad]

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.

Right, if it's the default legal status, your work is done for you. I don't understand how a law like that is legal, but I am all for it. You would be stunned by the number of people who want brand and expect to get it for the same price as generic. Stunned.

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?

It's because of caremark. CVS is trying to reinvent the relationship between pharmacies and PBM's. One of the major things about most of their new programs is trying to save patients (and insurance companies) money. The particular program I am referring to is CSI - Customer Saving Initiative. I know I have poked fun in the past about everything at CVS being tracked, but that's because it is true. Yes, stores are graded on how many "opportunities" are successfully switched over. The computer identifies opportunities and the pharmacist (not the tech) is expected to sell the customer on the idea of trying the cheaper regimen. I personally think it is a great program, but there are pharmacists who hate it and basically do whatever they can to avoid doing it. Same as every other program.

 

[owlegrad]

Exactly! And that's precisely what I think samples encourage prescribers to do. What is the point of samples if it's not to encourage prescribers to write full scripts for those meds? Drug companies aren't giving away samples to "help the poor" or to save patients money.

I was trying different migraine meds and got samples for a specific brand. It worked ok so I tried to fill the full script. Insurance rejection city!!! Got some generic sumatriptan and it worked just fine. As well as the pricey brand anyway.

My podiatrist gave me samples for Zipsor... a fancy new NSAID. Wasn't any more effective for my pain than ibuprofen or naproxen. Didn't even try to fill that script b/c what was the point?

Dear God, a new NSAID?! Hadn't heard of it, but what is the point? Give me a break.

 

[All4MyDaughter]

Right, if it's the default legal status, your work is done for you. I don't understand how a law like that is legal, but I am all for it. You would be stunned by the number of people who want brand and expect to get it for the same price as generic. Stunned.

The law here is that all scripts will be filled with a LOWER (not lowest) priced generic alternative (per Orange Book) unless the patient or physician objects. Pharmacists do not have to ask. Generic is the default. The law must be posted in every pharmacy.

A physician cannot have a blank printed that says "Do not substitute" and expect that his RXs will be automatically filled with brand. He has to make an "affirmative mark" on the RX every time. If "Do not substitute" is printed on the blank it must be circled or checked or underlined or something. Or he must write "Dispense as written" or similar. Always. Can't be automatic.

Pharmacies are not required to stock brand name anything. So if a physician or patient requests an expensive brand, the pharmacy is under no obligation to order the med and fill it. I have seen patients turned away who were demanding brand name on something that the pharmacy only stocked generic. As in "No, will will not order brand name Monkeyturdcillin for you because it only comes in bottles of 1000 and you have a script for #14 and we'll never sell the other 986."

Of course (and this is the big factor) a physician can say "Do not substitute" all day long and the patient can say "I want the brand" until the cows come home, but insurance companies are under NO obligation to pay for brand when generic alternatives exist. So that's how most people who start out wanting brand eventually get generic. $$$$ talks.

It's because of caremark. CVS is trying to reinvent the relationship between pharmacies and PBM's. One of the major things about most of their new programs is trying to save patients (and insurance companies) money. The particular program I am referring to is CSI - Customer Saving Initiative. I know I have poked fun in the past about everything at CVS being tracked, but that's because it is true. Yes, stores are graded on how many "opportunities" are successfully switched over. The computer identifies opportunities and the pharmacist (not the tech) is expected to sell the customer on the idea of trying the cheaper regimen. I personally think it is a great program, but there are pharmacists who hate it and basically do whatever they can to avoid doing it. Same as every other program.

Interesting! Thanks for edumacating me! 🙂

 

[All4MyDaughter]

Dear God, a new NSAID?! Hadn't heard of it, but what is the point? Give me a break.

I guess new is the wrong term. It's diclofenac potassium, but in some gelcap formulation that supposedly has a special release mechanism blah blah blah. I wasn't impressed.

http://www.zipsor.com/

 

[museabuse]

the metric is around 98%. This means if a generic is available, 98 percent of scripts must be filled for generic. It is actually hard to meet. If you get on family and they have 20 scripts between them and their copayment is the same $2.50 no matter if brand or generic then you are screwed. We have prinivil, robaxin, vicodin, fioricet, and all kinds of special order brands for them. We have tons of synthroid and percocet brand only customers. These all ruin your metric. You really can't do anything about this metric because you can't convince them if they don't care about price.

However there are other metrics the company cares about more. For certain insurance companies the company knows it is x dollars cheaper to switch from diovan to losartan, or lipitor to lovastatin. When you fill an rx for diovan it gets flagged and you must try to change them to losartan. It is possible you can get fired if you don't meet this metric.

Therefore some pharmacists will call and get it changed without asking the patient. Not because they get a kickback or make more profit, because they want to meet the metric so the district manager stops emailing threats about losing job if metric doesn't get met. Mainly because the district manager looks good to their boss and the district manager gets huge bonus, not measly pharmacist(they are a dime a dozen)...

 

[litetigre]

So far the kickbacks I see are MTM and some inhaler crap. MTM will pay you $5 every time there's a TIP that you convince doctor to change to generic alternatives. The inhaler crap happen with Medco, they prefer Ventolin over Proair or Proventil. I believe you got $20 first time pt fills Ventolin, no incentives for refill though

 

[owlegrad]

I guess new is the wrong term. It's diclofenac potassium, but in some gelcap formulation that supposedly has a special release mechanism blah blah blah. I wasn't impressed.

http://www.zipsor.com/

Ah, a new formulation. Got it. I wondered how I could have missed a new NSAID, but stranger things have happened. I am also unimpressed.

 

[confettiflyer]

And I don't mean generic substition. I mean "Doctor wrote for Lipitor. Copay is ONE MILLION DOLLARS. Can we switch to generic simvastatin?"

Whoops, but yes same thing going on, then it was the third party payer that drove the conversation.

Not covered/copay a million dollars? Patient didn't want it.
$20 brand copay (vs. $10 copay)? Patient was fine with it.

We didn't push for substitution if insurance covered it and patient was okay (and could afford copay), because we just didn't have time for that ****.

 

[owlegrad]

the metric is around 98%. This means if a generic is available, 98 percent of scripts must be filled for generic. It is actually hard to meet. If you get on family and they have 20 scripts between them and their copayment is the same $2.50 no matter if brand or generic then you are screwed. We have prinivil, robaxin, vicodin, fioricet, and all kinds of special order brands for them. We have tons of synthroid and percocet brand only customers. These all ruin your metric. You really can't do anything about this metric because you can't convince them if they don't care about price.

Yeah, museabuse is correct, it only takes a handful of synthroid, warfarin, keppra, etc. patients who only want brand and you have blown your metric. It gets annoying too, because like A4MD mentioned you are under no obligation to stock the brand, but how many patients do you want to turn away? If someone fills 10 rx's a month, do you want to lose that patient over one brand-only request? It is surprisingly common.

Having said all that, like museabuse points out, that is not one of the more important metrics. It is also not impossible to meet, sometimes you get lucky and don't fill that many brands. As long as you are education patients and doing your due diligence, it shouldn't be a problem. Like every other metric, many pharmacists consider themselves above needing to worry about such things - I see their point on this one.

 

[All4MyDaughter]

I bet CVS stores in this state have less trouble meeting that metric. I have never *seen* the brand name products for most of the drugs you mentioned. Synthroid would be the exception. Fair number of people on brand name Synthroid. But I'm pretty sure I've never held a bottle of brand Prinivil or Robaxin in my hot little hand...

Disclaimer: never worked for CVS so someone who does might have a different view.

 

[WVUPharm2007]

lmfao at anyone that think there is any difference in generics of an instant release drug.

It's Xmg of a molecule. It's not the Colonel secret herbs and spices, here. That **** is measured to ridiculous accuracy. There is absolutely no logical or scientific reason any of them would work differently.

One ****ing person has their INR change on Warfarin or have a seizure on generic Topamax and the specialist thinks it was because of the drug...completely discounting the fact that changes in condition with those types of drugs are more overt due to frequent labs and physical manifestations...

...I swear I hate people...

 

[All4MyDaughter]

lmfao at anyone that think there is any difference in generics of an instant release drug.

It's Xmg of a molecule. It's not the Colonel secret herbs and spices, here. That **** is measured to ridiculous accuracy. There is absolutely no logical or scientific reason any of them would work differently.

Someone in the other thread said (paraphrasing), "When I write for brand name Coumadin or Synthroid, there's a good reason." I'm really curious what those reasons might be.

 

[rph3664]

But I'm pretty sure I've never held a bottle of brand Prinivil or Robaxin in my hot little hand...

I have, but then again, I graduated in 1994. Not long afterwards, there was some "bonus" (i.e. kickback) program that involved switching people from Prinivil to Zestril, or maybe it was the other way around. That was rapidly discontinued when the company got so many complaints from pharmacists, who weren't doing anything but dealing with these insurance rejections.

At that time, I worked at a mail order place and we ordered Vasotec in bottles of 10,000. They were about the size of a gallon jug, and had about 50 desiccants in them that had to be removed before the Baker cells could be filled.

We also used a lot of Persantine. That's been largely replaced by a daily aspirin.

 

[Praziquantel86]

I bet CVS stores in this state have less trouble meeting that metric. I have never *seen* the brand name products for most of the drugs you mentioned. Synthroid would be the exception. Fair number of people on brand name Synthroid. But I'm pretty sure I've never held a bottle of brand Prinivil or Robaxin in my hot little hand...

Disclaimer: never worked for CVS so someone who does might have a different view.

I saw brand everything when I worked at CVS, this being at a store in one of the top median income counties in the U.S. We had a dermatologist who would have his secretaries write, by hand, "DAW" on every prescription blank as they came in from the state. We ended up having random crap like Kenalog in Orabase stocked just for his folks...on top of the HydroDiuril, Zestril and Prinivil, branded Z-Packs, Medrol Dosepaks, Mevacor, Lopid. Brand-name Zocor was on our fast-mover shelf.

These folks would switch to a brand-only equivalent within the same class as soon as a generic came out for what they were taking. Didn't even want to be associated with it I guess. Our substitution rates were routinely in the low 70s, in a 5,000 script a week store in a mandatory substitution state. Not so good. Yet another reason I gave up on retail.

 

[WVUPharm2007]

Someone in the other thread said (paraphrasing), "When I write for brand name Coumadin or Synthroid, there's a good reason." I'm really curious what those reasons might be.

Allergy or intolerance to inactive ingredient is the only rational reason.

I don't give a damn about their perceived anecdotal evidence of Mrs. Jones' INR going down to 1.7 after a switch. Mrs. Jones is a noncompliant kook and the human mind makes people connect the dots that aren't there.

 

[All4MyDaughter]

Allergy or intolerance to inactive ingredient is the only rational reason.

I don't give a damn about their perceived anecdotal evidence of Mrs. Jones' INR going down to 1.7 after a switch. Mrs. Jones is a noncompliant kook and the human mind makes people connect the dots that aren't there.

Yes, I have heard of (rare) confirmed allergies to excipients. That would be a valid reason. But usually what I hear from physicians (and this gets old, frankly) is "I just think it works better." OK... 🙄

 

[All4MyDaughter]

This was posted in the other thread. It seems a bit biased to me. Other thoughts?

What they don't tell you about generic meds

 

[ifillrxs]

The MTM company my employer is contracted with provides TIPs(Therapeutic Interchange Program) for their Medicare Part D patients. I am given a list of patients taking expensive brand name meds such as Crestor, Lipitor, Diovan, Avapro. If I can get the patient switched to a less expensive generic alternative, my pharmacy receives twenty dollars.

 

[rxlea]

This was posted in the other thread. It seems a bit biased to me. Other thoughts?

What they don't tell you about generic meds

I love how they quoted an Arizona pharmacist 😉

We have had a few patients come through the hospital that had confirmed allergies to excipients. I have also seen a couple of psych patients respond poorly to the switch to generic (the anticonvulsants topamax and lamictal specifically). I think there is some truth to what this article is saying, particularly when you consider the variation in how well a certain patient metabolizes a drug. I don't know... I think there needs to be more research in this area. My take on it is that if the patient is starting the drug for the first time, a generic substitute will be fine. If the patient has been on the drug for a long time, you can TRY a generic substitute but will need to monitor the patient closely- but really only for certain drugs. Substituting for generics is, in general, a good practice but I will somewhat agree with the article that for some drugs and some patients, you need to be more cautious.

EDIT: and yes, I agree it is is biased. But, like I said, the heightened concern should really only be for certain drugs. I would say that most patients do well with the conversion (in my experience) but there will always be the few that respond poorly for whatever reason and it is best to just get them back onto the brand. Sucks if it is really expensive though 🙁

 

[393656]

Psych meds and synthroid are extremely common for people to not respond to the generics. Especially Clozapine (worst), wellbutrin XL and a lot of the SSRI's.

I do not think its possible for a pharmacist to "switch" someone. I write a script and specify whether I want generic or name brand and I have never had someone call me or tell me that the pharmacist wanted to switch them. I would be shocked if that happened or you would hear outcry from physicians. If this were the case, can you imagine the extra work/time involved in speaking to the pharmacist about every time they wanted to switch a patient to generic. Or if they did not inform the physician and the patient decomponesated on generic than who is responsible...

 

[WVUPharm2007]

Psych generics "don't work as well" because people have convinced themselves that the generic isn't as good. I guess I can kind of understand that..but only because patients have a heightened sense of themselves during the period of switching medications. I remember the month Zoloft went generic. We switched everyone to the Greenstone generic that was made in the EXACT SAME FACTORY using the EXACT SAME INGREDIENTS. And wouldn't you know it...a dozen or so people SWORE it didn't work as well. It blew my mind.

I had the same thing happen to freaking Toprol XL. A physician SWORE that it made a patient's HTN worsen. Yet if you read the side of the bottle what does it say? "Manufactured for Par Pharma by AstraZeneca in Sweden." What does it say on the side of the brand Toprol XL bottle? "Manufactured by AstraZeneca in Sweden." Yup...same factory...same ingredients. It's these original manufacturer generics released on their generics subsidiary's banner that has proven to me beyond a doubt that this entire issue is mostly conjured out of thin air.

Fascinating, isn't it, that nobody has ever claimed that the generic version of a medication works better than the brand name?

This is why there should be no such thing as brand names.

 

[All4MyDaughter]

Psych generics "don't work as well" because people have convinced themselves that the generic isn't as good. I guess I can kind of understand that..but only because patients have a heightened sense of themselves during the period of switching medications. I remember the month Zoloft went generic. We switched everyone to the Greenstone generic that was made in the EXACT SAME FACTORY using the EXACT SAME INGREDIENTS. And wouldn't you know it...a dozen or so people SWORE it didn't work as well. It blew my mind.

That's what I think too. It's psychological. I'd like to see a double-blinded RCT. I think it would demonstrate that it's all in their head. Of course, psych trials are kind of difficult anyway because of the nature of the symptoms and illness.

I once had a patient throw a FIT because we dispensed him a new generic. I think it was pantoprazole. I opened the bottle and it was the exact same capsules as the brand name Protonix. I mean, it even said "PROTONIX" on the capsule. Showed the patient and he said was like... "Oh."

 

[All4MyDaughter]

Psych meds and synthroid are extremely common for people to not respond to the generics. Especially Clozapine (worst), wellbutrin XL and a lot of the SSRI's.

I do not think its possible for a pharmacist to "switch" someone. I write a script and specify whether I want generic or name brand and I have never had someone call me or tell me that the pharmacist wanted to switch them. I would be shocked if that happened or you would hear outcry from physicians. If this were the case, can you imagine the extra work/time involved in speaking to the pharmacist about every time they wanted to switch a patient to generic. Or if they did not inform the physician and the patient decomponesated on generic than who is responsible...

The only time most pharmacists bother is when the patient's insurance won't pay for the brand name, or charges the patient a copay so high that the patient refuses to pay. At least in my experience.

 

[CUpharmD2013]

Psych generics "don't work as well" because people have convinced themselves that the generic isn't as good. I guess I can kind of understand that..but only because patients have a heightened sense of themselves during the period of switching medications. I remember the month Zoloft went generic. We switched everyone to the Greenstone generic that was made in the EXACT SAME FACTORY using the EXACT SAME INGREDIENTS. And wouldn't you know it...a dozen or so people SWORE it didn't work as well. It blew my mind.

I had the same thing happen to freaking Toprol XL. A physician SWORE that it made a patient's HTN worsen. Yet if you read the side of the bottle what does it say? "Manufactured for Par Pharma by AstraZeneca in Sweden." What does it say on the side of the brand Toprol XL bottle? "Manufactured by AstraZeneca in Sweden." Yup...same factory...same ingredients. It's these original manufacturer generics released on their generics subsidiary's banner that has proven to me beyond a doubt that this entire issue is mostly conjured out of thin air.

Fascinating, isn't it, that nobody has ever claimed that the generic version of a medication works better than the brand name?

This is why there should be no such thing as brand names.

Either this or keep the brand name after the drug goes off patent and just have different manufacturers. Maybe require the generic companies to have to pay a trademark fee for the right to use the brand name. The reason that there are brand names is for marketing purposes and name recognition for the patient. Lipitor is a lot easier to remember than atorvastatin to the lay person. Once a drug goes off patent, the "brand" should no longer be available. If Pfizer still wants to make Lipitor, they need to price it competitively to generic companies. If they were to do this, many patients may choose to stick with the original manufacturer as opposed to switching. If Mr. Resident above wants all his patients on brand name medications then he better be writing DAW on his scripts because some pharmacies and some insurance companies require generic conversion and without the DAW we are authorized to make the change.

 

[All4MyDaughter]

Either this or keep the brand name after the drug goes off patent and just have different manufacturers. Maybe require the generic companies to have to pay a trademark fee for the right to use the brand name. The reason that there are brand names is for marketing purposes and name recognition for the patient. Lipitor is a lot easier to remember than atorvastatin to the lay person. Once a drug goes off patent, the "brand" should no longer be available. If Pfizer still wants to make Lipitor, they need to price it competitively to generic companies. If they were to do this, many patients may choose to stick with the original manufacturer as opposed to switching. If Mr. Resident above wants all his patients on brand name medications then he better be writing DAW on his scripts because some pharmacies and some insurance companies require generic conversion and without the DAW we are authorized to make the change.

Automatic generic substitution is the law in my state. Yes, physicians can write "DAW" on scripts, but they have to specify it EVERY time and pharmacies are under no obligation to carry the brand name product and insurance companies are under no obligation to PAY for brand name. The vast majority of the time, brand is not medically necessary. No matter what anyone wants to claim. 🙄

 

[museabuse]

Automatic generic substitution is the law in my state. Yes, physicians can write "DAW" on scripts, but they have to specify it EVERY time and pharmacies are under no obligation to carry the brand name product and insurance companies are under no obligation to PAY for brand name. The vast majority of the time, brand is not medically necessary. No matter what anyone wants to claim. 🙄

I guess I don't understand your law. So if the patient wants brand the dr has to write DAW on the rx? So if the dr writes percocet without saying DAW, then the pt is going to get generic even if they are willing to pay more for the brand and you have it instock?

In my state we always dispense generic unless the doctor writes daw or the pt requests it. We don't ask the pt we just do it, but it's not a law that I am aware of.

 

[All4MyDaughter]

I guess I don't understand your law. So if the patient wants brand the dr has to write DAW on the rx? So if the dr writes percocet without saying DAW, then the pt is going to get generic even if they are willing to pay more for the brand and you have it instock?

In my state we always dispense generic unless the doctor writes daw or the pt requests it. We don't ask the pt we just do it, but it's not a law that I am aware of.

The law in this state is that a lower (not the lowest) priced generic must be dispensed (if one is available) unless the patient or the doctor objects. For the physician to object, he or she must make an "affirmative mark" on the RX - either write DAW or DNS or something else. If "DAW" is printed on the blank it must be circled or checked or otherwise marked each time (can't be the default). If the patient doesn't want generic they have to tell the pharmacist when dropping off the RX and the pharmacist will write "Patient prefers brand" on the RX. The law must be posted in every pharmacy and the pharmacist does not have to ask the patient their preference. It's up to the patient to volunteer it.

In your percocet example, since there is no DAW the patient will get generic percocet unless they tell the pharmacist otherwise. If they say they want brand and it's in stock and they are willing to pay, they'll get brand. So, the patient can request brand but pharmacies do not have to stock it and insurance doesn't have to pay for it.

 

[museabuse]

The law in this state is that a lower (not the lowest) priced generic must be dispensed (if one is available) unless the patient or the doctor objects. For the physician to object, he or she must make an "affirmative mark" on the RX - either write DAW or DNS or something else. If "DAW" is printed on the blank it must be circled or checked or otherwise marked each time (can't be the default). If the patient doesn't want generic they have to tell the pharmacist when dropping off the RX and the pharmacist will write "Patient prefers brand" on the RX. The law must be posted in every pharmacy and the pharmacist does not have to ask the patient their preference. It's up to the patient to volunteer it.

In your percocet example, since there is no DAW the patient will get generic percocet unless they tell the pharmacist otherwise. If they say they want brand and it's in stock and they are willing to pay, they'll get brand. So, the patient can request brand but pharmacies do not have to stock it and insurance doesn't have to pay for it.

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?

 

[owlegrad]

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?

Yeah, what a bizarre law. Giving generic is the default here in FL for sure. DAW1=physician preference, DAW2=patient preference. Other DAW codes exist as well, like generic out of stock and such. But dispensing generic is the norm, we don't ask we just do it. It's not the law though, it's just good business.

 

[393656]

Psych generics "don't work as well" because people have convinced themselves that the generic isn't as good. I guess I can kind of understand that..but only because patients have a heightened sense of themselves during the period of switching medications. I remember the month Zoloft went generic. We switched everyone to the Greenstone generic that was made in the EXACT SAME FACTORY using the EXACT SAME INGREDIENTS. And wouldn't you know it...a dozen or so people SWORE it didn't work as well. It blew my mind.

I had the same thing happen to freaking Toprol XL. A physician SWORE that it made a patient's HTN worsen. Yet if you read the side of the bottle what does it say? "Manufactured for Par Pharma by AstraZeneca in Sweden." What does it say on the side of the brand Toprol XL bottle? "Manufactured by AstraZeneca in Sweden." Yup...same factory...same ingredients. It's these original manufacturer generics released on their generics subsidiary's banner that has proven to me beyond a doubt that this entire issue is mostly conjured out of thin air.

Fascinating, isn't it, that nobody has ever claimed that the generic version of a medication works better than the brand name?

This is why there should be no such thing as brand names.

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.

 

[owlegrad]

🙄