The Dispense As Written Codes that I use regularly in my practice are:

DAW 0 = NO PRODUCT SELECTION INDICATED

DAW 1 = SUBSTITUTION NOT ALLOWED BY PRESCRIBER

DAW 9 = SUBSTITUTION ALLOWED PLAN REQUESTS BRAND

Why is this important?

Dispense as written codes are important in billing/filing claims correctly to a patient’s insurance plan. Claims must be billed/filed correctly so that patients receive the appropriate drug products at the correct price.

For me… DAW 0 is used most of the time (this holds true for most pharmacists), while DAW 1 is used sparingly; a drug example for those who are not Pharmacists as to when a Pharmacist uses DAW 1 is seen in the case of  prescribing Brand Name Synthroid. Prescribers often write for Brand name Synthroid instead of Levothyroxine because this drug has a Narrow Therapeutic Index (NTI). Due to the NTI, formularies often include both the Brand and Generic products on their formularies so that patients receive appropriate pharmaceutical treatment for their thyroid conditions.

If you’re interested in reading more about NTI, please visit the FDA’s website and review the powerpoint “Quality and Bioequivalence Standards for Narrow Therapeutic Index Drugs.”

So…DAW 9?

DAW 9 is increasingly becoming popular and being put into place by Pharmacy Benefit Managers (PBM’s). Typically generics have been dispensed because the generic product is the cheaper alternative when compared to the brand name product. However, increasingly manufacturers have been offering PBM’s rebates for the monies that they pay the pharmacies on the drugs cost.

In short…even when prescribers write a prescription and sign Product Substitution Permitted — the pharmacist must dispense the brand name product for the product to be covered by the patient’s insurance. This is done by changing the computer DAW code from a 0 to a 9.

So you may be asking, “how is it more profitable for the PBM’s to have higher priced drugs on their drug formularies?” I found a great article published by NCPA entitled “PBM Revenue Streams and Lack of Transparency”. The article is a quick read and outlines why Brand Name products continue to be on formulary even when a generic competitor enters the market.

Examples of using DAW 9 in my practice (Generic Drug — Condition Treated)

Dexmethylphenidate ER — ADHD

Diazepam Rectal Gel — Seizures

Methylphenidate ER — ADHD

Budesonide Respules — Asthma

What’s the effect on people and the market?

In my practice this leads to a major consultation point…

• You and/or your family member is on a drug that insurance is requiring that Brand Name be dispensed (DAW 9). I’m not sure if your local pharmacy carries the Brand Name or Generic product. Thus, it is imperative that you contact your pharmacy days in advance to ensure this product is in stock when you attempt to refill your medication. If you don’t call ahead of time, this could potentially delay when you receive your medication, which could lead you to become non-compliant with your medication(s).

The reason that this is so important…

• Finding the medication for your patient is important…but ensuring that your patient has access to this medication is just as important. If they can’t obtain or access the medication, then you can’t ensure their compliance on the medicine. And non-compliance ultimately can lead to hospital readmission.
• When patient’s transition from an inpatient admission to being discharged to the outpatient setting, prescribers are often unaware of what’s on or not on the patient’s drug formularies. This can lead to confusion and delay and/or impede discharge planning which can potentially lengthen their hospital admission.

DAW 0 versus DAW 9 seems like such a trivial issue, but the increased prevalence of this small change can impact our patient’s compliance and can drive up the cost for providing healthcare.

If you have Questions related to this topic? Please feel free to leave a comment.

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Sam Blakemore is the Pharmacy Manager of Peds Rx Pharmacy Solutions. Connect with him via: LinkedIn