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Concern contractors left ‘out of pocket’ with new levothyroxine advice

PSNC: We want to put the burden back on prescribers, as they should know the correct process
PSNC: We want to put the burden back on prescribers, as they should know the correct process

New MHRA guidance about prescribing levothyroxine could leave contractors with the choice of being “out of pocket” or face telling prescribers to re-issue scripts, pharmacists say.

According to a Medicines and Healthcare products Regulation Agency (MHRA) guidance update on levothyroxine issued last week (May 19), healthcare professionals should “consider consistently prescribing a specific levothyroxine product known to be well tolerated by the patient…if a patient is persistently symptomatic after switching levothyroxine products”.

However, there is concern that this advice would lead to contractors losing out in cases where the prescriber does not enter the correct product description – selecting the generic, rather than the specific brand name – in their prescribing systems. The NHS Business Services Authority (NHS BSA) system for calculating reimbursements only reads the drug line.

The Pharmaceutical Services Negotiating Committee (PSNC) said it is “aware that some pharmacy contractors have been left out of pocket because prescribers have free-typed product information (such as brand name or supplier) into the dosage instructions field or notes section of electronic prescriptions, and the pharmacy has not been reimbursed for supplying in accordance with the prescriber's instructions”.

If pharmacists are presented with such prescriptions, “it is strongly recommended to have [the scripts] appropriately rewritten/re-issued by the prescriber before dispensing to ensure that it can be accurately priced by the NHS BSA”, PSNC stressed in an update on its website last week (May 21).

Take the hit or spend time calling GPs?

James Milner, a locum pharmacist based in Dudley, told C+D that contractors are “left with a choice of ignoring the instructions or taking a hit on the price” by dispensing the product incorrectly entered onto the prescription.

While Vikesh Patel, superintendent at Weston Pharmacy in Upton Park, said in response to PSNC’s advice: “What a joke. The dispensing fee is as it says on the tin – fee paid for dispensing. Where has the calling the GP come from?”

“When will PSNC learn not to be a ‘yes sir’ organisation and […] shift some of the burden to the GPs?” he stressed.

A PSNC spokesperson said: “We know we’re saying that the pharmacies need to go back to the prescriber, but really we’re trying to push the burden on to the prescribers because the prescriber needs to be the one [making the changes].

“As soon as they’ve changed it once, it would hopefully [make them] realise they need to do that going forwards,” they added.

“Dispense the brand you did previously”

Expanding on the reasons behind the new prescribing guidance, an MHRA spokesperson told C+D that: “Generic prescribing remains appropriate for patients treated with levothyroxine. The advice follows reports that a small number of patients experience problems when their product is switched. This includes switching between different generic brands.

“The recommendation for those patients who experience symptoms after switching is to maintain them on the specific product or brand that is well-tolerated, including generic brands. There is no recommendation to switch to a more expensive brand leader product,” they stressed.

“The advice for pharmacists is that the patient should receive the same brand that they have been tolerating well that has previously been dispensed by their pharmacy.”

PSNC director of pharmacy funding, Mike Dent, reiterated the negotiator’s advice for pharmacy teams to seek to get the prescription corrected.

“PSNC has a dedicated pricing audit team who check prescriptions are paid correctly as well as staff who ensure the Drug Tariff is kept up to date. It is through their work that we are able to identify any potential areas of concern and develop guidance to raise awareness,” Mr Dent explained.

“We also continue to work to make the dispensing process as straightforward as possible for contractors – this is difficult work, as neither we nor NHS England and NHS Improvement can tell prescribers how to prescribe other than through guidance.”

What do you make of the new levothyroxine prescribing guidance?

Mr CAUSTIC, Community pharmacist

are the licence numbers on almus and teva boxes the same ???


John Cleese, Production & Technical

But then if we get the GP to write the prescription as "Levothyroxine [TEVA]", and the next month Teva is unavailable, we'll need to get the prescription changed AGAIN to give another manufacturer's version (assuming the patient wants another brand instead of nothing at all). What a carry on.

M. Rx(n), Student

This is where, in a transparent and effective system, as Professionals in positions of public trust, the ability and expectation to intervene on clinical/professional grounds needn't be an otherworldly requirement.

Mr CAUSTIC, Community pharmacist

Bob which generic brand does this ? I would have thought theproduct licence number of the original manufacturer should surely be on the box . Perhaps David Kent might like to comment on this !

Really? Wow, Superintendent Pharmacist

Correct - currenlty Almus Levo 25mcg is actually Teva inside. 

Bethan Jones, Community pharmacist

Almus do this

Mr CAUSTIC, Community pharmacist

The answer is simple adapt the payment system to read the instruction line and pay if it contains a specific brand .    


has PSNC approached the government to do this ? I bet they haven't .

Have the LPC put forward that idea ???

It will not suit the government to make life easier for the pharmacist if it increases costs and what does the PSNC do   ....... as usual nothing .

Time for the PSNC to be paid on results . Let their pay increases be voted on by the contractors . No successful negotiations no pay increase ! After all if we do not see our income increased why should theirs be !

Adam Hall, Community pharmacist

"Face the possibility of asking prescribers to reissue the prescription" - You make it sound like it is a terrifying and terrible thing to do! If we are to enable "Teva Divas" then prescribers will need to shoulder their portion of the grief. There is no problem here: "My doctor says I have to have XYY brand" - "Fair enough - go back and get them to issue the prescription with that on it". It will only take one or two trips back for either patients to give up and take what they get (for FREE!) or for GPs to catch on and issue the prescription correctly the first time. 

David Kent, Community pharmacist

Only one????

Bob Dunkley, Locum pharmacist

My misgivings with this is that sometimes what is in the box although it is the correct levothyroxine and correct strength, has been made by a different manufacturer, and the patient who has been stabilised on one “brand” now receives another. I can think of one generic “manufacturer” who doesn’t make the tablets in the box, all they do is assemble the finished article, buying their strips of Levothyroxine from whoever is the cheapest. Presumably the generic manufacturers are going to be drawn into this latest wheeze of the MHRA to ensure that the generics we buy are going to be the same next month as they are this month.

C A, Community pharmacist

Yet, I'll bet you've come across patients that will swear blind that only that brand works, and that Teva is rubbish... when it's Teva inside the box at the minute.

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