When to Request a Pharmacy Review: Case Manager Decision Guide
Know the trigger points for medication review referrals
Published: 3 April 2026 | Updated: 3 April 2026
The Question: Does Your Claimant Need a Pharmacy Review?
As a case manager, you manage dozens or hundreds of claims. Most don't need a medication review. But some do. How do you know which? This guide gives you a clear decision framework.
A pharmacy review makes sense when you have questions about medication safety, appropriateness, or whether medications are helping or hindering your claimant's recovery. If you're thinking "I wish I understood whether this medicine is right for my claimant," that's a signal a review could help.
Primary Trigger: Medication Complexity
The single biggest trigger for a pharmacy review is medication complexity. If your claimant is taking four or more medications, the risk of problems rises sharply. Interactions become more likely. Side effects become harder to attribute. Coordination becomes difficult.
You don't automatically need a review for every claimant on four medicines. But if your claimant is on four or more and any of the secondary triggers below apply, a review is warranted.
| Medication Count | Review Urgency | Action |
|---|---|---|
| 1-3 medicines | Low | Only review if significant concerns present |
| 4-6 medicines | Medium | Consider review if any secondary trigger present |
| 7+ medicines | High | Review strongly recommended |
Secondary Triggers: When to Definitely Refer
These situations suggest a pharmacy review is needed:
Side Effects Affecting Function
Your claimant reports drowsiness, dizziness, or other side effects that limit their ability to work, participate in rehabilitation, or engage in daily activities. This suggests medications may be part of the problem. A pharmacy review can identify which medicine is causing the effect and explore alternatives.
What to do: When your claimant mentions side effects, specifically ask: "How is this affecting you? Can you do your physio? Can you concentrate at work?" If side effects are limiting function, refer for a review.
Recovery Plateau Despite Appropriate Treatment
Your claimant isn't progressing as expected. Physio is appropriate, the injury is healing, but functional improvement has stalled. Medications may be limiting recovery. Pain medicines causing drowsiness, antidepressants affecting motivation, or benzodiazepines reducing engagement can all slow rehabilitation.
What to do: If progress plateaus, discuss with your claimant: "You're on a lot of medicines. I want to understand whether any of them might be holding you back." A pharmacy review can identify whether medication optimisation might unlock progress.
Compliance or Adherence Issues
Your claimant admits they're not taking medicines as prescribed. They forget. They stop taking them because of side effects. They don't understand why they need them. These are red flags that the medication regimen isn't sustainable or appropriate.
What to do: Never judge; investigate. "Tell me more about why you're not taking this one regularly. Are you having side effects? Do you not see the benefit?" A pharmacy review can clarify whether the medicine is necessary and if there's a better option.
Medications from Multiple Specialists Without Coordination
Your claimant sees a cardiologist, neurologist, physiotherapist, and GP, and each has prescribed independently. No one is looking at the full picture. Risk of duplication, interactions, or conflicting approaches rises.
What to do: When you're aware multiple specialists are prescribing, request a pharmacy review to coordinate the regimen and flag any gaps or overlaps.
High-Risk Medicines Present
Your claimant is taking opioids, benzodiazepines, anticoagulants, or other medications with narrow safety margins. These require careful monitoring and optimisation.
What to do: If any high-risk medicine is present, especially in long-term claims, request a review to ensure it's being used safely and appropriately.
Escalating Costs in Pharmaceutical Expenses
Your claim's pharmaceutical spend is rising. New medicines are being added, or dosages are escalating, without corresponding improvement in function. This suggests the medication strategy may not be optimal.
What to do: When you notice cost escalation, request a review to identify whether deprescribing or optimisation could reduce costs while maintaining or improving outcomes.
Long-Duration Claims; Concern About Medication Dependency
Your claim has been open for more than a year. Your claimant is still on medicines that were prescribed in the acute phase. You wonder: are these still necessary, or is your claimant dependent on them?
What to do: For claims over 18 months, consider annual pharmacy reviews to ensure medications remain appropriate and plan deprescribing as recovery progresses.
Claimant Expresses Concern or Confusion
Your claimant says: "I don't like how this medicine makes me feel," or "I don't understand why I'm taking this," or "My doctor keeps changing my medicines." These statements indicate medication uncertainty or dissatisfaction.
What to do: When your claimant expresses concern about medications, that's worth investigating. A pharmacy review can clarify whether concerns are valid and explore alternatives.
Decision Matrix: Should You Request a Review?
Use this framework to decide:
| Scenario | Decision | Reasoning |
|---|---|---|
| Claimant on 2 medicines, recovering well, no side effects | No review needed | Low complexity; no red flags |
| Claimant on 4 medicines, all appropriate, no concerns | No review needed now | Moderate complexity but no triggers present |
| Claimant on 4 medicines, reports drowsiness affecting physio | Refer for review | Side effects limiting recovery; medication optimisation needed |
| Claimant on 6 medicines from 3 specialists; no coordination | Refer for review | High complexity; polypharmacy risk; specialist coordination needed |
| Claimant on opioids; long-term claim; duration >18 months | Refer for review | High-risk medicine; long-term; deprescribing planning needed |
| Claimant on benzodiazepine; poor recovery progress | Refer for review | High-risk medicine; recovery plateau; functional limitation |
Timing: When to Request a Pharmacy Review
The best time to request a pharmacy review depends on your claim's phase:
Acute Phase (0-6 weeks)
Early review is valuable if medications seem complex or problematic. This is when medications are newest and most easily changed. Early intervention prevents entrenchment.
Early Recovery (6 weeks-3 months)
This is an ideal window for medication review. Your claimant's acute phase is resolving. It's clear what medications are needed long-term. Deprescribing can begin if appropriate. This is the most impactful timing.
Established Chronic (3-12 months)
Review is valuable if problems have emerged: side effects, poor compliance, recovery plateau, cost escalation. Don't wait if concerns are present.
Long-Term (12+ months)
Annual medication reviews are valuable. These prevent entrenchment of unnecessary medications and help plan safe deprescribing as recovery progresses. If opioids or benzodiazepines are present, annual review is important.
How to Make a Referral
Requesting a pharmacy review is straightforward:
- Gather current medication list (from your claimant or their GP)
- Collect relevant medical history and treatment records
- Provide brief context about your concern (e.g., "Claimant reports side effects affecting function")
- Refer to IMM (your insurer will facilitate this)
- Inform your claimant: "A medication specialist will review your medicines to make sure they're right for you"
The rest happens automatically. The pharmacist will contact your claimant, perform the review, and deliver a report to you and your insurer.
After the Review: Your Next Steps
Once you receive the pharmacy review report:
- Read the executive summary and recommendations
- Discuss findings with your claimant in plain language
- Share the report with your claimant's GP or treating specialist
- Work together to implement recommendations gradually
- Monitor your claimant for improvement (reduced side effects, better function, better compliance)
- For long-term claims, consider annual follow-up reviews
Cost Considerations
Cost of a pharmacy review is typically modest and is far outweighed by benefits in most cases. Reduced medication costs, shorter claim duration, and improved outcomes quickly offset the review cost. Don't let cost concerns prevent a needed review; discuss this with your insurer.
Make Better Medication Decisions for Your Claimants
When you're unsure about medications, a pharmacy review provides clarity. IMM's expert assessment helps you and your claimant make informed decisions about medication strategy and optimisation.
Request a Medication Review
