Most complex concept in medicine – the Do Not Substitute box

I’ve ranted about how DAW-1s in the past, however a good chunk of “doctors” out there cant seem to understand exactly what it means when that “Do Not Substitute” box is checked.  I use the word “doctors” in quotes because I am also referring to people who write prescriptions such as NP, PA’s and the extremely clueless Dentists and Certified Nurse Midwifes.

In California (and pretty much every state), pharmacist have the authority (which are few and far between, trust me) to switch from a brand name drug (Prilosec) to an FDA rated generic alternative (Omeprazole).  We can do this all by ourselves!  7 years of college and a doctorate degree and doctors have trusted us with the power to switch the Brand to the Generic of a SINGLE DRUG without their all-knowing permission.  I’m sure that when this law was snuck under the doctors nose they shit all over themselves!  In fact, most pharmacists love it when doctors write the old brand name because I’d rather see “Adderall” than “Mixed Amphetaminescribblescribbledontknowwhatcomesnext”.

Now here is where the confusion comes in.  That little box that says “Do Not Substitute”, that is to prevent us from switching from the BRAND name to the FDA approve generic FOR THAT DRUG.  Idiots seem to think that we have the authority to switch from a Brand name to ANY GENERIC, we don’t.  Unless you work for a hospital, have some P&T committee overseeing you, or have some collaborative practice agreement; pharmacists CANNOT switch to a completely different drug (even in the same class) without the doctors approval.  We can just switch from the BRAND to the GENERIC of the SAME CHEMICAL.  See how simple? Obviously not.

What blows my mind is when Dentists (*sigh*) check that box and write for Amoxicillin and Ibuprofen.  So I read that the Dentist (*double sigh*)  does not want me to auto-substitute a generic for… the… generic that he/she… uh.. just wrote for…. yeah.  Certified Nurse Midwifes (uh, yeah, they can write for Rx’s and we cant, how’s that kick in the nuts towards our profession) LOVE to forbid me from substituting Docusate.. uh.. for docusate… hmm..  These people have prescriptive authorities?  They don’t even understand what that damn little box means!  “Oh, I don’t want this pharmacist substituting a generic alternative for this GENERIC THAT I’M GOING TO WRITE FOR!”  I’m sure that DDS’s and CNM’s have their reasons for needing prescriptive authority, they could at least do their profession some justice by not sloppily abusing that privilege.

The other end of the spectrum is when MD/NP/PA’s write for Lipitor and check the little idiot “Do Not Substitute (DNS)” box.  Uh, is there a generic out for Lipitor?  Why are you preventing me from switching to a generic that hasn’t even come out yet?  Do you even know what that little box does?  Obviously not.  Single-source drugs (meaning drugs that come from one source, hence the name) doesn’t require you to check the little “DNS” box because there isn’t anything to substitute them for (hence, single source)!

Then you call the doctor up and call him on it because obviously the insurance company is NOT going to pay for a brand name that costs 100x more than the generic just because he checked a little box.  What response did you get?  “Oh, the generic is fine.”  I really feel like answering “WASTE MORE OF MY TIME BY CHECKING THAT MOTHERFUCKING BOX YOU ASSHOLE!!”  Doctors can be so damn frustrating at times.  All that college and they can’t understand a simple concept like the DNS box on their Rx pads.

Don’t get me started on OB/GYN’s and checking that fucking box on prenatal vitamins or iron tablets.

If the state allowed us to switch a non-covered brand to a class-equivalent brand/generic (meaning switch the whole drug to another in the same class) then I can see them checking the box for everything.  However we can’t switch drugs, so checking that box just because you have no idea what it means just makes yourself look like an idiot.

This has been a Public Service Announcement by The Angry Pharmacist.

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90 Comments

  1. Megan says:

    If this were facebook, I’d click the “like” button :)

    • Kate Allsion says:

      Oh, but there are those of use whose script pad come automatically with two lines to sign: substitution allowed _____________________ or fill as written _____________ AND there is a box to choose “label.”

      • DDH Pharmacist says:

        Several years back, Texas law changed on that. The script pads used to have 2 lines. Now the “Fill as Written” or “Brand Necessary” or whatever is on the paper doesn’t count. If you don’t *WRITE* “Brand Medically Necessary” or “Brand Necessary”, then we can fill it with a generic.

        And then, if the patient wants the brand, if there’s insurance, they may be charged a higher copay, *if* the brand is covered. And the patient wants us to call their Dr for a “Brand Necessary” notation.

    • RxAnnie says:

      I love when they write DAW on amoxicillin too. I’ve actually called a couple of offices asking exactally which brand of amoxicillin they wanted me to dispense. Occasionally, maybe 25% of the time, this solves the problem. Either way, I’ve taken out some frustration on a deserving office.

    • rebecca says:

      The day after I read this rant I saw a customer’s script from a cardiologist written for carvedilol 6.25. Signed dispense as written. Couldn’t help laughing to my self and thinking about TAP. Stupid doc.

  2. Sandi says:

    I don’t mind them checking the box for a single source med. I put the DAW on it and if a generic comes out before that prescription is expired, then I know not to waste my time. A DAW on a generic is usually idiotic, but hey, if you want to tell me which manufacturer you want, then, by all means! Otherwise, it’s product selection rather than generic sub. And the prenatal vitamin thing gets me too. NONE of the prenatal vits are in the orangebook, so NONE of them should be substituted, but since EVERYBODY DOES ANYWAY, I have to hear it from these girls who say “they gave me a ‘generic’ at pharmacy x down the street!” Oh and I love it when the prescriber writes do not sub on a generic and the patient yells at me that I gave them generic instead of brand. I quit.

  3. Dr. Grumpy says:

    Very good points, TAP. Remarkably overused little box there, and creates insane amounts of paperwork and hassle.

    I try to write brand names (usually they are shorter) and NOT check the box unless the patient has had a specific problem with a generic in the past (epilepsy patients, because of the narrow therapeutic windows they need, are usually the only ones I’m a stickler for brand name).

    One other issue- the guidelines for script pads are NOT federally regulated. Some will say we don’t need more government involvement in this issue, but on this point I think it would be nice.

    We have 50 states, each with entirely different laws about what the script pad should say. Some have a box marked DAW. In some the box says DNS. In some there are 2 signature blanks at the bottom, and you sign on the left for brand name, and on the right for generic. In others you sign on the right for brand name, and left for generic.

    Since many patients travel, they may get scripts filled out of state, confusing the local pharmacist. And if a pharmacist or doctor moves to a new state, they need to learn the new system. I think the FDA should pick one script pad DAW/DNS format, and make it mandatory nationwide to minimize medication errors.

    • P3 Pamela says:

      On the other end of the spectrum, I love it when the doctors write the generic name of brand-only drugs and tell the patient that “the brand name has been out for a couple of years so the generic has to be available now, too.” Then I’ve got patients bitching at me that I want them to pay more because I won’t give them the generic that doesn’t exist because their polished turd of a doc says it does. Or, they have a script for the brand name and the MD specifically writes on there “substitution allowed.” They then tell the patient/lead the patient to believe that, if the brand name med doesn’t have a generic, then we can switch to another drug which does come in generic. When we call to switch to a generic med, the doctors imply that we are wasting their time by reminding us that they said a substitution was allowed and are shocked when they find out what that really means.

      • Katrina CPhT says:

        lol…. been out for a “few years:…. Don’t they know it takes 15 years starting from the application process for anyone to jump on making a generic?

    • sumotoad says:

      Grumpy, you are always the voice of reason in an unreasonable world. I wish I could say you can trust the pharmacist to help you with the narrow TPI drugs…. but apparently there is a GED for pharmacy school nowadays based on what my employer is hiring lately. I am truly sorry.

      • Dr. Grumpy says:

        Trouble is that sometimes even this issue is out of the pharmacist’s hands. The chain is always negotiating for a lower priced generic, so the specific generic brand of, say, Carbamazapine may chenge from month to month, each with it’s own pharmacokinetics. So the pharmacist can only work with whatever meds the bean-counters in back supply him with.

        I once had a patient bring in a refill of generic Carbamazepine that had 3 different brands of generics in the bottle! So for my epilepsy patients I usuaully insist on brands only. For other conditions, I’m less concerned.

        • SCPharm says:

          It is always good to ask the patient if they all come from the same pharmacy. Just because they are in the same bottle does not necessarily mean that they came from the same pharmacy (since many patients have made a sport out of transferring their prescription monthly from pharmacy to pharmacy to win gift cards, free hams, etc…) Different pharmacies will often dispense AB rated generics from different manufacturers than their competitors and patients often combine bottles. Instead of forcing the patient to pay more for the same therapy by default, consider educating the patient on the importance of using one pharmacy and explain the reasoning behind using a consistent brand or generic. Patients on more cost-effective therapy demonstrate better overall compliance, which is most important in acheiving positive therapeutic outcomes.

    • RxDawg says:

      I think the FDA should pick one script pad DAW/DNS format, and make it mandatory nationwide to minimize medication errors.

      Agreed

      • Katrina CPhT says:

        I received a faxed over prescription the other night. 10 prescriptions all written in cursive about a size 9 font relatively. I faxed it back and wrote, “This prescription is illegal. Please print.” :)

  4. ndenunz says:

    Is it a majority of the docs?
    Personally, I allow generic substitution for everything (yeah, even Coumadin, Synthroid and Lanoxin). Don’t see that much difference.

    • sumotoad says:

      Yer a good lad, doc, and I love ya

    • Faye says:

      Synthroid is vastly differnt than levothyroxine, for some people. I am one of those people. After having switched to levothyroxine, I now have a goiter. My new doctor put me on the SAME DOSE of synthroid (to begin with) and I feel a world of difference. Also, my bloodwork is much better. Please don’t assume that you know how a generic will work for someone else’s body. With some drugs I don’t notice a bit of difference between the brand and generic. With other drugs, I definitely notice a difference. Since we all have unique body chemistries I think that it is somewhat arrogant of you to assume that a generic is fine for everyone for every drug. Simply isn’t true and you are toying with people’s health. Perhaps if you or a loved family member had an ineffective generic your point of view would change on this. We all know that quality control standards on some generics would allow for some batches to be scaled to the weak side of the allowable variance. So, please, get real.

      • Another Angry Tech says:

        Faye,
        You as the patient always have the choice to take brand name drugs. That big sign in the pharmacy that says we “can substitute a less exspensive alternative” either begins or ends with the words “unless you do not approve.” It’s things like Synthroid (and a handful of others) that we try to be extra cautious about switching from brand to generic or even to different generic manufacturers. We have patients that ask for specific manufacturers for their meds and we comply; it’s our job to make sure that you get what works for you. However, it’s a two way street. You (the patient) have to work with us (the providers) to make sure that youre getting the right thing. For every one person who needs to take a brand name drug, there are twenty others who would raise hell for even suggesting that they take a something other than generic. There is nothing wrong with people wanting brand name drugs but there is something wrong with not being able to substitute when it benefits the patient, their insurance, and the pharmacy.

  5. Cracky McCrackhead says:

    Those DAW’s are important to me. I want the name brand Dan’s and Soma’s.

  6. Love says:

    The midwifes are the worst in my experience.

    Most don’t seem to understand the DNS ticky box and I don’t know how many times I’ve seen them write a full year’s supply of BC for each refill, with four refills (I’m not sure if they can write for BC in the US, but they can here). Or how about not writing any refills on the prescription, depsite telling the patients that they wrote for a full year (and then getting mad at us for getting it wrong when we call about it).

    Ridiculous.

  7. Cody says:

    This is all a good point, but the worst is when the patient (and then the doctor) get mad at us for substituting a generic when the MD legally didn’t DAW it. I don’t know if this is a state thing, but at least in mine, the doctor cannot just sign above the “Dispense as Written” box, they also have to circle the DAW or write DAW beside the drug for it to legally be a binding DAW script.

    For some reason, SO many prescribers don’t seem to know this, OR believe this, and continue just signing above the line. So we keep filling generics or using DAW-2 so the insurance charges patients more =D

  8. william says:

    Maybe you should have been a doctor since you know so much more than they do? What I’m trying to say is, just fill the prescription for whatever it says. If costs more for the patient, show them the checked box, say your hands are tied bc of that, have them go back to their doctor to get it fixed.

    • sumotoad says:

      In case you weren’t paying attention, amigo, we are all doctors and in California at least have been since 1965….. I’m just saying. I’m assuming you’re a colleague and so I love ya.

    • KUMoose says:

      Yes, because telling patients that you’re hands are tied is an excellent way to get people to come back to you. And an even better use of my time then the current 7 ball juggle I’m doing now. *cough*

      • Greg Kramp UofFindlay Student says:

        KUMoose,

        Althought it is not IDEAL situation to tell a patient that “your hands are tied” it is often effective especially if you are in a busy pharmacy. In the end all problems are the patient’s responsibility. When I’m paid some of their problems, become MY problems. Patients are often unsatisfied with the turn-around time in fixing common pharmacy problems (this blog seems to be dedicated to the little thanks that we get for putting in extra effort), by giving the problem back to the patient they may walk in our shoes and be more understanding of the work we do.

        Several lines are very effective for quelling problem patients(NOT patient’s with problems – we all have problems, but we aren’t all pains):

        1) I don’t have that medication (this is a lie and gets problems out of the store).
        2) I’ve called the MD with no result, why don’t you call him
        3) At this point it’s in the doctor’s hands
        4) “I don’t know” — this works great with questions really meant for an insurance company.
        5) When a patient asks, “What should I do?” (often after hearing about a large ticket price) tell them “Don’t take it, you don’t need it.”

        By NOT demanding some respect from customers you are SURE to get more problems from customers.

        As retail pharmacists we are more drug delievery experts, than fixer of all ills. If the MD’s fixed alot of the problems they were supposed to, half the people wouldn’t need drugs. So your ability to fix their problem is not your problem.

  9. Gern says:

    And when there is a box that they should check, they dont even consider it. Like the new check boxes for how many tablets they wrote for (to prevent diversion). They completely blow that off and then check the do not substitute box? WTF.

  10. pharmer says:

    Not to spin this to a T19 rant….., but<
    Patient's mom comes in, "did the doctor call in little Johnny's Lamictal?"
    Pharmer "Yes, its all set, $0 copay."
    Mom "Oh, but its that other one."
    Pharmer "Its the generic equivalent."
    Mom "Well next month I'll talk to them to make sure its brand."
    Pharmer wants to tell mom brand costs $140.13 vs generic $2.48. Pharmer wants to tell mom if Johnny can take it this month then brand is not medically necessary. Pharmer wants to ask mom if she had to pay the extra $137.65, would it still be brand medically necessary? Pharmer wants to ask mom if brand is 56 times better?
    Pharmer "OK, have a nice day."

  11. $4 Slave says:

    Longer im in this profession, longer that I learn there are alot of stupid/lazy people out there.

    I wish there was a mandatory law passed on prescriptions. ALL Dr. information is to be printed UP top. If the DR works with many..then guess what…no more 100 names up top. Just 1 DR on a RX form per Dr.

    Why you ask? Because when they decide to sign their name with a checkmark and have 100 names up top…then you ask thee patient who they saw of which you get the answer ” I dont know he was there”….I dont have to go through the sh*t of hunting him down cause the patient and Dr are too lazy to take the time to provide the information we need we can do our jobs.

    • sumotoad says:

      I frequently ask the patient, “Which doctor wrote this?” and since they don’t know, I can’t help but ask, “You let some guy from India root around in your guts and you don’t even know his name?”

  12. MB says:

    It might be funny if it was not so true. I really want to smack the idiots who write this crap on the script every time I see it.

  13. another pharmacist says:

    My favorite are the doctors who write brand medically necessary or DNS on prescriptions for TriCare patients or for patients on medicaid. Both of these are mandatory generic plans….We then have to waste time calling them to get the okay to use generic.

  14. Pharmacy Kid says:

    “Certified Nurse Midwifes (uh, yeah, they can write for Rx’s and we cant, how’s that kick in the nuts towards our profession).”

    I know, wtf, right? However, the tides are slowly turning. In New Mexico and the Carolinas, there are now CPP’s (clinical pharmacy practitioners) who write scripts regularly. Also, there are pharmacists who can DIAGNOSE AND PRESCRIBE. WTF? How is this possible? Click below to learn more

    http://www.usphs.gov/corpslinks/pharmacy/pharmpac/practices/pcp.html

    • eighthchord says:

      It’s progressive, at the very least. I’m at UNC and am considering the clinical pharmacy practitioner path. Unfortunately, most doctors (by that I mean MD’s, not PharmD’s, even though we are doctors by definition, too, in this country) are very resistant to pharmacists knowing more about drugs than themselves. Funny, because that is what our entire schooling is focused on. Drugs. They studied about 4 months of pharmacotherapy. And they do not trust us with our 4 YEARS of studying pharmacotherapy. It’s hilarious and debilitating simultaneously. I haven’t received a cue yet to shake the role of “pill counter”. I am just that annoying SOB that calls when they check the “do not substitute” for the Medrol dose pack.
      I know I said I would not read your posts again because you do not agree with the public health option, or socialized medicine ( not the same thing, but I forget which you wrote about), but your posts are just too funny.

    • KS says:

      I’m an amb care pharmacist with the VA, and working under a Scope of Practice, I’m able to monitor, prescribe, and change medications for patients consulted to me by their PCP.

  15. sumotoad says:

    It has never failed to amaze me that the people who know the least about drugs get to prescribe, and those who know the most get to do squat. I remember as a student (pharmacist baby) doing rounds with the doctor babies and asking, “So, how many semesters of pharmacology do you dudes have, anyway?” They said, “One”. I have six years of nothing but drugs, drugs, drugs and more drugs…. and they can prescribe. What thrills my desiccated soul to this day is when the patient says, “I’d call my doctor, but he don’t know shit compared to you anyway….”

  16. SH says:

    At least in Fla. A “doctor” must write medically necessary in their own handwriting. If they check a box or have one of those lovely computer generated rx’x… too bad, so sad. If I think the pt actually wants the brand. I fax a copy of the rx, with a copy of the statute. and tell them rx has to be rewritten or called in properly. My small contribution. First thing looked at in an audit know a pharmacy that just lost $28,000

  17. kizell says:

    I can’t tell you how many times I see shit like Vicodin 5/325, Percocet 5/650, Lorcet 5/500…..and yesterday, a nurse (of course) called in Coumadin 4mg QD (split into 3 and 1 mg tabs). 2 hours later, the same doctor’s office, different nurse, fax in a script for Coumadin 2.5mg 5 days a week, and 5mg for the other 2 days. Or how about the time the nurse calls in a prescription for “whatever he got last time for cholesterol with 3 refills.” Why don’t they just say, “I’m too much of a lazy fucking whore to get up off my fat fucking ass to grab the patient’s chart, so I’m going to ask you to do all the work. Thanks fuckstick.”

    • Greg Kramp UofFindlay Student says:

      With many of the problems that have been presented, I usually solve the problem by documenting the change and NOT calling the MD. I like to think this falls under the pharmacy practice laws where a pharmacist shall “interrpret the prescription.” Nowhere does it say that the pharmacist will be mindless and call the MD with every little problem, even if the correct solution is clear. Most of these are not ambiguous problems so I do not bother the MD. Like any other profession we are firstly “problem solvers.”

      Kizell, It’s probably an oversight, but there is nothing inappropriate with Coumadin 2.5 mg on some days and 5 mg on others. Albeit this might seems inconvient for the patient so is having A-fib.

  18. Mike W. says:

    At least for WV and for PA (the 2 states that I’ve worked in) we ignore all checked boxes or signatures on certain lines. Unless the doctor writes “brand medically necessary” in his/her own handwriting on the original prescription we are REQUIRED by law to subsititute the generic equivalent. Also for those that are waiting for standardized prescription pads….you won’t have to wait much longer. All rx’s will be e-scripts within the next couple of years.

  19. Mary-Helen Chaplin says:

    This may be the only thing Texas does right, but in order for them to instruct us NOT to substitute, the physician has to right (in his or her own handwriting, no stamps) ‘Brand Medically Necessary’. However, we do still have two-line pads circulating and we usually have to call and clarify if they sign over the “Do Not Sub” line.

  20. OMpharmstudent says:

    I am just beginning my first year of pharmacy school in Mississippi (so you can imagine the obese, incompetent people who walk through the pharmacy door…when 95% of scripts are medicaid not to mention the numerous NPs who walk around with their drug book and can’t even spell Xanax correctly…but don’t correct patients when they mistakenly refer to them as “Dr…whatever” and write scripts for purple drank prometh with codeine by the gallon) but I just wanted to say that I enjoy coming to read your posts to free my mind from all the “professionalism” brainwashing and kool-aid drinking I am being forced to take in every single day. While trying to recruit students, the dean told us we would be promised a job and that we would be involved in the ‘most trusted profession in America’. On the first day of orientation, however, he proceeded in telling us that more than likely we wouldn’t have a job upon graduation, maybe because of this health care plan the Obammunists are proposing? Our pharmacy program was just changed to seven total years. But we likely won’t have a job because of government healthcare and the economy? Fuck me. Anyhow, thank you for allowing me to have a realistic glimpse into pharmacy.

  21. the misunderstood profession says:

    Grrrrrr. Here’s a bloodboiler. It seems as if most of the dental offenders result from assistants/hygenists writing the scripts on the DDS’s RX pad. I caught my own hygenist a couple of years ago with a DAW on a Prevident. I made her rewrite it and let the DDS know. If I want sparkles and fancy flavors, I’ll request it myself.

    Related to the whole DAW/multiple-MD on RX thing–what is it with MD’s and the aversion to checking boxes? (Not you, Dr. Grumpy, you actually get it–AMEN!). Not only was this a problem in retail, but it’s a problem in hospitals, too, with all of the pre-printed order sets agreed upon by P&T to make everyone’s life “easier”. Transfer orders with no boxes checked, some with all boxes checked with meds that cannot be safely given on unmonitored floors, meds checked without the appropriate frequency box checked appropriately, etc. AAAARRRRGGGHHHH! I don’t get how highly educated people cannot understand a simple method of communication that takes next to no energy. Thanks for the great post.

  22. newb says:

    what drives me crazy that is also along similar lines as this topic are Rx pads that have “Void if more that 1 rx is written per blank” or something like that. More often than not do I get these with multiple rx’s on them. I hate calling back on something so trivial as that.

    • ALBPharmD says:

      Better yet, when the “void if more than 1 rx written per blank” is crossed off/scribbled out by the MD! Um…sorry…that just doesn’t work!

  23. RxDawg says:

    What response did you get? “Oh, the generic is fine.” I really feel like answering “WASTE MORE OF MY TIME BY CHECKING THAT MOTHERFUCKING BOX YOU ASSHOLE!!”

    This about made me piss myself. Just an FYI, they are working to push for the authority for pharmacists to make theraputic substitutions (switch to another drug in the same class). Pretty much all the data says this wins for everyone. Perscriber, patient, and pharmacist. I work in a hospital setting is this is a godsend. Of course, it will probably take 20 yrs or so to make any kind of change.

  24. Tobin RPh says:

    This was one of my (many) pet peeves as well back when I was a community pharmacist. Thank God those days are over! In Washington State, we have two signature lines on Rx’s and the one on the bottom left says “Substitution Permitted,” and the one on the right says “DAW.” Many prescribers always sign their name on the “DAW” side, whether they are writing for Vicodin, Perocet amoxicillin etc. I solved the problem in my pharmacy by not stocking any brand name drug that had an AB rated equivalent, and when the doctor signed DAW I called and told them that they either had to authorize the generic or send the patient elsewhere. The doctor (actually the M.A, since I never got to speak to the doctor) always said that the generic was ok, but then I would get 500 of the same Rx’s later, all written for brand name and DAW. I would stop calling after the hundredth one and assume that the generic would again be OK’d.

    My preference would be that if the prescriber wants brand, he/she would have to write out “do not substitute” or similar in own handwriting.

  25. Well Illbe says:

    I agree with you on most points angriest except… If a drug currently has no generic and dr doesnt check the do not sub box, if the generic becomes availale before the rx expires guess what happens? The big chains pull the switcharoo on the patient in the middle of therapy without asking etc and if the PMBS audit you half way through and you have brand Topamax filled that was writen 11 months ago but the generic came out two months ago, they are taking the dinero back for the past two months….

    • Cody says:

      Um, actually, I make it a point to ask when I’m typing/renewing a script that has a new generic. It’ll save time later. And you’re acting like it’s such a tragedy and sin to start a generic in the “middle of therapy”, plenty of patients are thrilled that their $50 drugs will go down to $10, and have no complaints from the generic.

  26. WazzupharmD says:

    Fortunately, Washington state plans have a therapeutic interchange program (TIP) that lets us switch from a brand to a covered generic in the same class.

    So… when your average dumbass ARNP/PA writes for Nexium (or Kapidex! It’s so much newer and better!) because they’ve been convinced/bribed by a drug rep, we can do the sensible thing for everyone and switch them to omeprazole or pantoprazole.

    Every state should do this.

  27. kizell says:

    In Georgia, if the Dr. doesn’t write out “Brand medically necessary”, I don’t give a flying fuck what boxes they check. They’re getting what I give them.

    • the narc nazi says:

      kizell, I love it!! I am a tech working in both a hospital & retail setting. Can I come work for you??

    • Georgia RPh says:

      Deciding I like Georgia pharmacy laws…..had no idea those silly boxes actually had to be paid attention to in other states. What a hassle! Love telling patients who tell me, “The doctor wanted me to have brand b/c he wrote the brand name on the script” too darn bad. If he didn’t write “Brand Medically Necessary” in his own handwriting, I am legally allowed under Georgia State Law to fill it for generic. Only time I check with docs is new patients on epilepsy meds for epilepsy. Don’t want that on my conscience.

  28. Bama "Pharmist" says:

    Gotta love Alabama Medicaid. Not only must the doc sign on the DNS line, AND write “Brand Medically Necessary” in his/her/its own handwriting (and it must be a written RX! No phone in DAW1s!), they must now get PRIOR AUTH!! This requires a lovely form to fill out, as well as a MedWatch 3500 form (which Medicaid will forward to the FDA). Woo hoo, more paperwork for the docs! (Coumadin and a couple of other drugs are exempt from the PA requirement)

    I think Medicaid did this, in part, to cut down on all these docs who are DAW1/BMN happy. It’s definitely cut down on the DAW1 RXs I see.

  29. Jube says:

    Where I practice the dr. must write “no sub”, not there – not given. I also love it when the patient comes in and says that they don’t want the ‘genetic’ stuff. What? Oh you mean generic. Brilliant.

  30. Christine says:

    TAP, you should know DAMNED well why they do that. Two words: DRUG REPS.

    Several years ago, my husband was put on Lipitor. After taking it for several weeks, he started getting severe stomach cramps. It didn’t take him long to see that the Lipitor was causing it. He told his doctor about this, but was ignored.

    So he ended up in the hospital, the one where his doctor practiced, for some other reason. They kept trying to force Lipitor down his throat, although he told them a thousand times that he had adverse reactions to the drug. I almost had to write NO LIPITOR on his forehead with a Sharpie to get the hospital nurses to quit trying to give it to him.

    Finally, one nurse was honest, and told us that the hospital had a *deal* with the people who make Lipitor, and they didn’t carry any other statin meds. Hubby’s doc’s daddy is on the board of directors of said hospital, and they are also in private practice together.

    To make a longer story shorter, Hubby did switch doctors, because of this quackitude.Now he is on a generic form of Zocor for his cholesterol, and it’s working just fine. No stomach cramps, no nothing, and it works. Ten bucks a month for the co-pay. The money was not an issue for us, though, it was just the nasty side effects.

    This is why I get mad when I hear the latest radio ads for Lipitor…*if your doctor prescribed this, it’s for a reason*. Yeah, and I know what that reason is…kickbacks from drug reps.

    And you know it, too, TAP. Thanks for this post.

  31. Kait says:

    I work for a dermatologist who LOVES to DAW Doryx for her acne patients. I am a former pharmacy tech (turned medical assistant, soon to be nurse- I’ll try not to be one of those retarded ones!) and I just want to punch her in the face. If only I could find a tactful way to explain what DAW is for without belittling her and calling her a fucktard.

    • Matt says:

      “I work for a dermatologist who LOVES to DAW Doryx for her acne patients”

      Anybody out there know why derms DAW everything? And not just the little checkboxes which don’t fly in OH. Just curious, but back in my days in the drugstore I saw several derms who wrote DAW on every single Rx he/she wrote (always prescribed trade names as well).

  32. Katy says:

    In Australia, it’s actually illegal for doctors to tick that box unless there is a reason for the patient to get the medicine (since the government subsidises the cost). Without this box ticked, the pharmacists may change the brand of medicine without the doctors permission. The front counter staff (as in, the people standing at the till) get training in educating patients about the difference between brand name and generic medicine (ie, none).

  33. Susan says:

    Angry Pharmacist or his cohorts-

    Are you getting any complaints about generic Imitrex not working as well as brand? I’m a chronic pain pt.- migraine and back (but I never ask for early refills even though my doc thinks C-ll drugs are the work of the devil and refuses to give them to me and my liver is going to rot). I don’t seem to get the same relief. Am I the only one?
    Thank you. Sorry to get off topic.

    • Shalom (R.Ph.) says:

      The generic Imitrex that we stock is by Dr Reddy’s Labs. If you read the fine print on the back, you’ll see it’s actually manufactured by Penn Labs division of GlaxoSmithKline, so it’s essentially brand name Imitrex with different markings on the tablet. Shouldn’t be any difference at all.

  34. James says:

    Hello to all pharmacists! I shall call myself James. I am not a pharmacist… I would like to share some of the brutality of what I see with your profession. I’ll make a simple list, it will be far more direct that way. This list is compiled through insight I have acquired from two of my friends who happen to be pharmacists.
    1. You should all be in Unions to control many aspects of your jobs.
    2. No limits to fills per day? Some of you fill fill 50, others up to 800! and, in general, earn the same salary? It would be nice to earn an additional $1 for each one over 50, right? I mean this is common sense here…
    3. Dust everywhere! Can you tell me what happens when you mix the powder of 200 drugs on a counter, in the a/c ducts and all over the store where you work via vacuum cleaner throwout? Probably a poison that may shorten all your lives.
    4. Many of you have no lunch break while everyone else gets one.
    5. “The customer is always right”?, I don’t think so, haha…
    6. You have no say in having to work straight from 8 am to 10 pm? No where else in the WORLD would a professional have to work such ABSURD hours.
    7. You are treated like children by the corporations you work for.
    8. You have to “multitask”? what? Phones, customers, refills often times without assistance. Is this what it means to be a pharmacist?
    9. POOR security! You have a 3’8″ counter to keep the masked gunman out from behind the counter where all the “much desired” pills are kept.
    10. If you don’t sell enough generic drugs you will be given a negative score at the end of the week. What?
    11. What about all the corporate material you had to read before you started working? How about the rest you have to read throughout the year? Are you being paid for that? I believe if you are forced to read it and take tests on the material, they should be forced to pay you for the time it takes. Information online says some pharmacists study up to 50 hrs a year to obtain and an additional 50 hrs a year to sustain their positions. Let’s see, 50hrs x $55 = $2750. Did any of you get paid for it?
    12. You often have the WORST health insurance available on the market!

    **Sorry for the rant, but you are not being treated as PharmD’s , Pharmacists or professionals. I am NOT affiliated with any Union, but all of you should be! I am aware of maybe 10% of what goes on at a pharmacy? but doesn’t my limited insight as a lay person show serious problems with your field? I especially pray for all of you due to the dust problem. What the Hell is going on here? You could bake a cake with 12 months worth of powder you wipe off the counter at each pharmacy!
    James

    • Robert says:

      I have been represented by a Union since the middle 1990s. What a waste of time. I have seen my dues go up at a much higher rate than my salary. All the unior rep cares about is who is paying the dues and who is paying the fair share. With the Union, my salary and benefits have lagged behind the rest of the area. No concern regarding working conditions or any other professional issue. Just can you dontate to our cause so we can get our guy elected, our bill passed, honest we are looking out for you. Union, please go away and quit looking out for me. I am not sure I will survie you looking out for me anymore than you already are!
      Robert R.Ph.

    • Drugslave says:

      Thank you for understanding.

  35. Stasia says:

    Screw her, just tell her that.I used to be a Pharmacy Tech, and I saw plenty of this stupidity. As for pharmacists, I worked with plenty of good ones. Though I can think of three that should lose their licenses due to neglect and absolute idiocy.

  36. Oh, I think I like it here. Comments and followers as well.

  37. Shalom (R.Ph.) says:

    I swear I have made the exact same rant on several occasions, nearly word for word. About an hour ago, for example, I called a doctor who had prescribed four tablets of Doryx for premedication before surgery; his secretary agreed with me that a $30 copay for 4 tablets was silly, and happily changed it to generic doxycycline tabs. Didn’t even ask the doctor.

    I just last week was on the phone with my software vendor and had them change the words “SUBSTITUTED FOR” on our Rx labels to “Generic for:”. The reason for this was the exact problem you discuss above, viz. nobody knows what “substituted” really means. It’s worst with the OCs, because the “generic” is also a made-up trade name. I have yet to see a pack that only says “Norgestimate and ethinyl estradiol tablets, USP”; they have to come up with some funky name like Previfem. Then the patients call you up and scream at you for giving them the wrong pills. (And why in hell do we need six different names for norethindrone?) This way it’s blatantly obvious that I didn’t just decide on my own whim to dispense a totally different med; everyone knows what the word generic means by now, even if half of them can’t pronounce it.

    (NY State Law is that if DAW isn’t written there and there is an orange-book substitute that is less costly, you MUST substitute. NJ gives the patients the option to choose the brand, although when they see the price difference it suddenly doesn’t matter as much to them. Both states also mandate the handwritten BMN for medicaid patients. In NJ, where more than one on a blank is legal, they have to write it after each drug.)

    captcha: Djinn bushings. I don’t even wanna know what that means.

  38. RBW says:

    Even better is when the VA patient didn’t call in his refill on time and wants to know why he can’t have the $8.00 atorvastatin generic like the VA gives him and why he needs to pay $95.00 for his Lipitor.

  39. Pharmgal says:

    Doctors do not use DNS boxes correctly. In CA if the box is checked DNS they also need their initals/signature next to the box otherwise it’s not an offical DAW-1. If a pharmacist in CA wants to change the DAW-1 status and calls the doctor to get approval to dispense the generic we basically have to shred up the original and re-write it as a telephone order. Also, for patients on brand (DAW-1) drugs that need authorization requests for more refills, per our laws the MD has to write on there AGAIN not to substitute and initial on every auth request. It’s too hard in the pharmacy to do all this, we have much more important things to do but technically an auditor can come in and get all the money back for scripts that incorrectly use DAW-1 codes.

  40. marsha says:

    Hi angry pharmacist, I have a question for you, one on one. Thanks, M

  41. APAP says:

    Here is a suggested topic for you Angry Pharmacist…how infurating it is when patients ask for your advice on OTC’s and after spending 20 minutes explaining the difference between all the products and how they each work, pros and cons etc and giving your recommendations they walk away with something other than your recommended product. If you aren’t going to follow my advice, don’t waste my time by asking me!

    • Katy says:

      I remember a customer coming in once with a chesty cough. no runny nose, no headaches, nothing, just a chesty cough. The customer wanted Codral (pseudoephedrine/paracetemol/codeine) and I told him it wont do anything for the cough, and he really needed something like bromhexine or guaphenisin to break it up. I informed him that purchasing Codral would be a waste of his money. Long story short, he walked out with a box of Codral (phenylephrine instead of pseudoephedrine, though) and back in two days later with antibiotics for a chest infection.

      On the other hand, I love being right. 😉

  42. GoingDental says:

    I have worked with dentists for well over ten years and believe me when I say that they’re not only retarded in the script department, they usually lack all basic common sense as well.

  43. aer73011 says:

    TAP, love your blog. This one especially hits home. We have a dermatologist who writes for (example) triamcinolone TARO BRAND NECESSARY. He also writes for brand necessary on every single thing he prescribes, which drives us up the wall.

    Anyway, I didn’t read all of the comments, but I just wanted to point out that a reason for a DAW 1 on a brand drug without a generic is that the practitioner may want the patient to remain on brand in the event that a generic drug comes out before the prescription has expired or run out. In PA, we can automatically make those substitutions (except where there is a DAW 1), and patients can actually request that brand be filled (again, barring a DAW 1). In NY, where I go to school, if a generic comes out, regardless of the DAW status, we still have to call to get the OK to fill the new generic, and patients can not request a brand name med be filled. Again, we’d have to OK that with the doctor’s office.

    Anyway, keep writing…my colleagues and I love to read and relate!

  44. marsha says:

    I think what we’re all ranting about is how such busy work takes from us day in, day out, and eventually- for me it took a little over a year, even though I’m older, much, after leaving the profession for 3 decades-we’re totally spent. Or call it pissed off to the point of murder!!!

  45. BlueTech says:

    What really get me is that half the time, doctors are just checking the DNS box to appease the patient! No, Mrs. Older-than-time, you can’t have brand tenormin. If your heart suddenly stops because anything with the name “Mylan” on it will kill you, then send me the funeral bill. Until then, STFU.

  46. Jonessa says:

    This is AWESOME! I would love to meet the author of this and shake their hand! Pharmacists get shit on every day in their profession and we take it. As a whole we just let prescribers do whatever the hell they feel like and we just sit back and kiss their asses.Why can’t pharmacists prescribe?? Hello- we allow PAs and CNPs (at least in Ohio) to write rxs and they have had like 2 seconds of pharmacology. I think we need to start standing up for ourselves!

  47. Makeen says:

    lol, i love this page! Im not a pharmacist, just a tech at walgreen’s working retail planning on a career in pharmacy but man do you hit the nail on the spot! Pharmacists are totally treated with no respect by customers and the chain you work for wont back you up it’ll back up the patient and say that their right and the pharmacist is wrong – then gove the pt a 50 or 100 check! I read that a pharmacist is the most trusted profession by patients – what a buncha bull! Well anyways I liked your page so much it inspired me to start a group on my facebook page “the annoyed pharmacy technician”. Alot of people sadly think that all the pharmacist does is count pills. If I had a penny for every time a patient told me “whys the wait time so long?? Its only 1 pill!!!” Anyways, love your page :)

  48. Doc Shazam says:

    FUnny, I never thought this box meant anything other than apparently, exactly what it means! ABout the only time I’ve checked this box is for myself when the generic Imitrex came out…but that’s a whole nuther blog post, lol.

    Anyway, I utilize my pharamcists often when I know what i DON”T know, so thanks for your help! Enjoying the blog, keep it up.

  49. railrph04 says:

    Ahhhh the memories of being an intern in NY State with a daw box.
    Oh how many times I had been irked by “doctors” that wrote daw but not in the box like it was supposed to be. BTW the daw box actually has official dimensions according to NY State law. Gotta luv it!

  50. I had a prescription friday morning for a compound of a 50:50 mix of clobetasol and Petrolatum. The physician wrote in capital letters, covering a third of the prescription blank, “BRAND MEDICALLY NECESSARY. DO NOT SUBSTITUTE” . The prescriber is a dermatologist. There was no dose form or strength of the clobetasol. I called the physicain’s office and started with the patient’s name and I was calling about the compound prescription. The physician quickly interrupted me to tell me he wanted the prescription compounded exactly as he wrote it. I told him I needed more information that he left off the prescription to be able to make the compound for our mutual patient. He then told me to tell the patient to take the prescription to a pharmacy that could follow his simple instructions. I took a deep breath and explained to him neither of the ingredients he wrote were brand names and that he did not list a dose form for the clobetasol. He then said, “Obviously I want the ointment and whatever the brand name is for clobetasol ointment. That is what I want.” If he does not know what the brand name is, how could it possibly be necessary?

    I processed the prescription for the compound using the brand Temovate. The patient said to forget it because of the copay. That all took 45 minutes of my time and I am suppose to just forget it. I guess he was expecting a $4 Wally World (aka Walmart) throw it in a bottle copay.

    Friday afternoon the dermatologist’s assistant called in a prescription for generic clobetasol ointment. The patient got the prescription, but still complained about his $15 copay.

  51. Nancy says:

    Lol…We have a doc who consistantly does not only checks the do not sub box but he also writes PRN refills for Controls. Luckily, the Pharmacist I work under is REALLY good at explaining to the “poor” customer that generic is better so sometimes, just sometimes, they request from their Doc. to prescribe the generic equivalent…
    But then we have the customer or two that insists we give them name-bra nd because the generic doen’t work, Then they bitch because their co-pay is so high so we MUST be ripping them off and that the’re gonna have to take their business elswhere not realizing that their insurance is going to pay the same no matter what. Man, people are stupid…
    Old people are the worst, too…I know that they can’t comprehend the concept of the Donut hole, but you would think that a small town doctor would KNOW they can’t really afford the Name-Brand but thry prescribe it anyway with the do not sub box checked.
    And BTW, as a tech. we usually get the shit-storm from the customers when their prices are too high. Thankfully, the male Pharmacist I work with comes to the rescue and deals with them. (a might bit impatiently at times) but he’s good & I respect him. Now the female Pharmacist I work with…THATS anither story.
    Anyway, I think I rambled myself off track from the original point, but it sure is amazing that this happens every where.

    Oh, and TAP…I LOVE your blogs. It helps me to not take things so seiously because we’re all in the same boat….not alone. Thank you for that….And thanks for the fluent use of swear words….Its a nice change. I’m always getting into trouble for swearing under my breath at work….so thank you:)

  52. Sometimes the DAW can affect the patient’s copay. I have one patient on Brand name Lipitor (obviously, cuz there ain’t no genetics available) and DAW-0 Lipitor is a “non-preferred brand” and has a $50 copay, however DAW-1 Lipitor magically becomes a “preferred-brand” and has only a $20 copay.

    Over the counter “paracetamol with codeine?” …I smell Aussie.

    When it comes to newly available generics it seems like most patients and a whole lotta doctors have this theory of “If it ain’t broke, don’t fix it.” If the brand name is working okay, don’t change and just STICK WITH IT!

    From what I know about generics (which is a whole lot more than anyone should) the differences between two manufactures of the same drug are about the same as the differences between two batches of the same drug made by the SAME manufacturer. In other words, that generic Keppra made by Mylan and that new batch of brand name Keppra made by UCB are equally as likely to result in a seizure.
    Doctors want to cover their own ass. If a patient asks their doctor if it’s okay to take this new generic Keppra, and their doctor says it should be okay, and the patient takes it and just by odd chance has a seizure… Who’s to BLAME??? Well, Doctor said it would be okay… So, of course, the doctor is going to say, “NO! you should stick with the Brand. I’ve heard stories of people who switched to the generic and had seizures (although there are about the same amount of people who have stuck with the Brand and still had seizures) but still, that’s irrelevant, and we don’t want to risk it.
    I had one patient on Keppra and when the generic came out the brand name required a PA. The doctor didn’t want the generic (surprise, surprise) and filled out all the necessary paper work for the PA, but the insurance said NO. He has to try the generic and if it doesn’t work (basically meaning if he has a seizure), then they might approve the PA (assuming he survives) >>(
    So, rater than switch to the generic, the doctor changed the prescription to a different strength of Keppra XR, which, since it has no generic, was covered. I think that is so much more risky and reckless than just switching to a generic version of the same strength of the same drug.

  53. VOS says:

    I have an office across the street from my pharmacy that e-prescribes all prescriptions with a DAW of 1 because its just “too hard for the nurses to know those generic names that come up in the system.”

  54. VS says:

    An intern I had the “pleasure” of working with (read: harassing multiple times daily because of the absolute dumbass things she did/wrote/ordered) did not understand this concept either. When I instructed her to check the do not substitute box on her scripts for immunosuppressants, she thought that box meant as written by her attending. Ummmm….she was the one writing the scripts, did she think he was coming behind her and checking her work??? Mind you, this was in September, after she had been “practicing” medicine for 3 whole months.

  55. PP says:

    I’m no longer surprised with ‘weird’ prescriptions anymore… I’ve seen consultants that don’t sign in the correct column… that don’t sign the 2nd rx of his 10 medication pt… that writes drug names like it’s a chinese logogram… and all the other ‘common’ error(?) that makes u feel like ripping the rx to bits… while ur already impatient pt is pushing ur arse coz u happen to be the last stop, and who thinks ur a total idiot, coz what’s so difficult to read a piece of paper rite???

    But… sometimes, we can’t really blame the Dr when a little mistake happens on the rx. I mean, we look at hundreds of rx a day so spotting an error is probably instantaneous. I do wish the system would dump the new Drs in the pharmacy for a mth or so to know how things work around here (Pharmacist dont have sole dispensing rights in my country), since most of the time wasted (which could have put to better use i.e. pt education) in the pharmacy is confirmation regarding the rx… coz by the time u confirm everything with the dr, the pt have waited so long that they dont even bother listening to your instructions… just like how a patient magically thought she needs to drink her A-scab lotion…

  56. blit says:

    Ahhmmm..ok, I get what you are saying about the generic scripts and the “do not sub” and we write a generic. And you singled out the DDSs. Well we are all guilty of being sloppy, but let me straighten you out on something..you made the comment that having that box on our script pads is basically circumventing you “right or entitlement.” No sir, that is not our privilege..when you were give that ability, that became your privilege. It’s our right because, in spite of your 7 years of education and your dr. degree, we are still the doctors caring for and looking out for our patients. You seem to have lost your role or place and you need to find it. We look to you guys to help with our patients care but you speak as if you, as a pharmacist, have some power or control over my ultimate decisions. You don’t.. I’ve had to deal with the occasional, highly educated bottle filler who has, on occasion, asserted themselves in-between me and my patient. I an notorious here for writing for brand. I know, as you should, that not all generics are as effective. A lot of them have a very low BA. I will not allow generic Valium, for example. I will not allow generic Norco or Lortab, especially at 5/500. That’s our right not our privilege. Find your place, sir.

    • So when you dont allow generic Valium, norco and lortab; and the patient screams at us wondering why she has to pay over $100 dollars for her medications (when the generic is $20), we should just have them talk to you and your office staff? Yeah, thats helping everyone out.

      Lets be realistic here, you dont have the ultimate decision, its the patient/insurance company and what THEY will pay for. Obviously you are too hung up with your trade-name only power-trip that you’d rather the patient go without any medication than a supposedly inferior generic.

      You’d be the kind of doctor that we would tell our patient to steer away from because of your inability to see the forest from the trees. Obviously you have no comprehension as to how much trade name norco/valium cost.

  57. SeattleNP says:

    Greetings from rainy Seattle! Your site and videos are fantabulous! I am a family practice NP, I own my own practice, worship my local pharmacists, always write for generics, and don’t let drug reps through the front door. Go easy on us NP’s, we’re not all dumbshits :-)
    P.S. I keep running into the phrase ‘purple drink’ in reference to promethazine/codeine cough syrup. I do prescribe it on occasion when a patient has a really painful deep cough, mainly so they can get some sleep. Is the ‘purple drink’ really that popular on the street? Doh! Am I one of those dumbshits after all?

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