Generic substitution by a pharmacist means that when a physician prescribes a specific medicine, the pharmacist either may, or must, replace it by a generic medicine. In 2004 generic substitution was legally permitted in 70% of countries surveyed. The exact rules vary. Where generic substitution is allowed, physicians can override a decision to substitute in 89% of countries by annotating the prescription. The pharmacist has a duty to inform the patient that a substitution has been made.

Generic substitution must be financially attractive to pharmacists if it is to be successfully implemented. Remuneration as a fixed percentage of the cost encourages delivery of originator drugs in Portugal and Spain. Choosing to dispense generics is financially neutral in Belgium and advantageous in France and The Netherlands.

Patient co-payment makes the patient aware of the cost of their medicines. It may take the form of payment of a percentage of the cost of medicine (36% of countries), payment if the selected medicine is above a reference price (34% of countries), a fixed amount per prescription or another form. However, the financial pressure dissipates if the patient has insurance above the minimum obligatory level (as is common in France). If the co-payment is a percentage of the cost of medicines, patients have a financial incentive to demand cheaper generic medicines. For instance, in Poland, physicians tend to prescribe generic medicines because they are conscious of the limited ability of patients to meet co-payments and because they have long-term, positive experience with generic medicines. Patient co-payments may reduce access and equity and there is a cost in operating the system.

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