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"It can always be interpreted as brand or generic, and if [a doctor] wants something in particular, they need to indicate that," Dr. Rafie said, noting that generics are FDA ap- proved as equivalent. In California, Dr. Rafie said the only time a prescription has to be filled as written is if the physician indicates "dispense as written"; oth- erwise it's open, she said. In her experience, Dr. Rafie said changes are made most often to provide patients with their insur- ance-covered or most affordable option, but in some cases, it's the patient driving the request. "Occasionally, patients will say they tolerated a particular product better—it may be a particular generic even. Sometimes when a medication becomes available in its generic form, there may be a handful of manufac- turers who make the generic product and patients may find, for whatever reason—it may be the inert ingre- dients—that they do better on one efficacy, he said, adding that he un- derstands choosing what is affordable for the patient. In rare circumstances, howev- er, changes without a physician's knowledge could have negative consequences on a patient's health. A survey conducted a few years ago revealed patients aren't too keen on these changes occurring without their doctor's knowledge either. According to the Federal Trade Commission, "Each state has a law allowing pharmacists to substitute generic drugs for many brand-name products as long as your doctor doesn't specify that the brand-name drug is required." 1 Other state-spe- cific laws govern how pharmacists might make prescription changes as well. In California, for example, Sally Rafie, PharmD, pharmacist spe- cialist, University of California San Diego Health, is legally allowed to change from a brand to generic or vice versa because they're considered equivalent medications. Perspectives on the practice of 'therapeutic substitution' A few years ago, T. Hunter Newsom, MD, Newsom Eye, Tampa, Florida, noticed a change in how prescriptions he wrote were being filled. "It doesn't matter what pre- scription I write, patients come back with whatever their insurance pays for," Dr. Newsom said. "We used to have 'dispense as written,' and you couldn't substitute anything … all of the sudden, it didn't matter what we wrote. Patients would go to the pharmacy and the pharmacy would switch it. It seemed like … they would change from one product to another because of what insurance would cover." Most of the time, Dr. Newsom said, these swaps, which usually involve going from a brand name to a generic, don't bother him. There is often not enough difference in by Liz Hillman, Staff Writer When pharmacists change prescriptions: How and why they do it continued on page 24 September 2017 • Ophthalmology Business 23

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