What to do when medication costs are escalating on a claim

A practical guide to identifying cost drivers and optimizing medication spend

Published: 3 April 2026 | Updated: 3 April 2026

Why medication costs spiral on claims

You've spotted a claim where medication costs are climbing faster than expected. A claimant started on basic analgesia; now they're on three different pain medications plus multiple adjuncts. The costs keep rising. Your first instinct might be to push for deprescribing, but that's not always the right move. Before you act, you need to understand what's actually driving the spend.

Escalating medication costs signal several possible scenarios. The claimant's condition may have genuinely deteriorated, requiring additional therapy. The treating doctor may lack confidence in the original regimen and is adding layers rather than optimizing. Or, more concerning, the claimant may be doctor shopping, obtaining duplicate medications from multiple prescribers. The solution depends on which scenario you're in.

Step 1: Audit the medication timeline and cost drivers

Start by mapping exactly what's been prescribed and when. Request the full dispensing history from the claimant's pharmacy. You're looking for three things: medication additions over time, cost per item, and frequency changes.

Look for patterns in the additions. If medications were added in response to clinical deterioration (e.g., imaging showed progression, physiotherapy notes document reduced function), that's different from medications being added reactively when the claimant reports persistent symptoms without objective change.

Identifying cost drivers in polypharmacy

High medication spend often sits within polypharmacy cases. The costs aren't usually on the primary pain drug; they're on the adjuncts. Expensive neuropathic agents, multiple muscle relaxants, high-frequency dispensing of low-cost items that add up: these are typical cost drivers. Newer medications cost more than established alternatives. If a claimant is on both pregabalin and gabapentin, or both amitriptyline and a newer SNRI, you're probably paying twice for single benefit.

Step 2: Assess clinical justification

Now look at whether the escalating medication spend maps to clinical improvement. Request the most recent treating practitioner notes covering the past 3-6 months. You're assessing function, not just symptom control.

The key distinction is this: if the claimant's work capacity has improved, pain is more stable, or they're engaging better with rehabilitation despite higher medication costs, the spend is probably justified. If costs are climbing while function remains flat or declining, something needs to change.

Step 3: Check for duplicate prescribing and doctor shopping

Before assuming the treating doctor is responsible for escalating costs, verify the claimant isn't consulting other doctors. Request a summary of all scripts filled in the past 12 months from the pharmacy. Are there duplicate medications? Different doctors prescribing the same drug class? Overlapping dates when two similar medications were being dispensed?

Doctor shopping is increasingly common on long-term claims. A claimant sees their treating doctor, doesn't get what they want, sees a second GP or pain specialist, fills that script at a different pharmacy, then cycles back. The claim doesn't immediately show duplicates because they're managed through separate pharmacies or filled as separate scripts on overlapping dates.

Step 4: Communicate with the treating doctor

Once you understand the cost drivers, contact the treating doctor. Don't lead with budget concerns. Instead, frame it as optimisation. Share the medication list and ask: "What's your strategy for managing this regimen? Are you planning to optimise these medications or add further therapy?"

Specifically ask whether each medication has been trialled at therapeutic doses and for adequate duration. Many escalating cost cases occur because doctors are adding drugs instead of titrating existing ones properly. If a pain medication is at sub-optimal dose, adding a second agent isn't efficient; it's doubling spend without necessarily doubling benefit.

Step 5: Refer for a pharmacy review when appropriate

If the medication cost is climbing and you can't clearly justify it through clinical improvement, refer for a pharmacy review. A pharmacist will analyse the entire regimen, identify duplicates, flag unnecessary medications, and recommend optimization strategies. This is particularly valuable if:

• Multiple medications target the same condition without clear escalation logic
• The claimant reports minimal symptom improvement despite increasing costs
• You suspect doctor shopping or non-adherence
• The treating doctor is unresponsive to cost concerns
• The claimant has multiple prescribers or pharmacies involved

Step 6: Implement a monitoring framework

Once you've addressed the immediate cost escalation, establish a monitoring approach to prevent recurrence. Track medication spend alongside clinical outcome measures. If costs rise again without corresponding functional improvement, trigger a review automatically.

Common scenarios and how to navigate them

Scenario A: Genuine clinical deterioration

Imaging shows disease progression. The claimant's work capacity has declined. Physiotherapy notes document reduced mobility. In this case, escalating medication costs may be appropriate. Your role shifts from controlling spend to ensuring the increasing medications are optimally chosen and monitored. Refer for pharmacy review to ensure the new regimen is efficient and free of duplicates, not to reduce spend.

Scenario B: Tolerance and dose creep

The claimant reports that medications that initially helped are becoming less effective. The treating doctor responds by increasing doses or adding agents. This is common with long-acting opioids and benzodiazepines. Before accepting escalating costs, explore whether a medication holiday, rotation, or switch might be more effective than simply adding more. Refer for pharmacy review specifically to assess tolerance management strategies.

Scenario C: Multiple prescribers, rising costs

You discover the claimant is consulting multiple doctors. Each prescriber adds to the regimen without seeing the full medication list. Costs escalate because the claimant is accumulating medications across multiple sources. In this case, refer for pharmacy review and consider whether a single responsible prescriber arrangement would improve coordination. You may also need to implement stricter approval controls or require treating doctor authorization for medications outside primary prescriber.

Scenario D: Costs rising, function declining

This is the scenario that demands fastest action. The claimant is taking more medication, at higher cost, and they're less functional than before. Either the medications aren't addressing the underlying problem, or the side effects are counterproductive. Refer for urgent pharmacy review to reassess the entire approach. This might require deprescribing, medication switching, or additional clinical investigation to identify whether the medication regimen is appropriate.

Key decisions at a glance

Use this framework when deciding your next action on an escalating medication cost case:

Summary: Your action plan

Escalating medication costs need systematic assessment, not reflex reactions. Your sequence should be: audit and understand the drivers; assess clinical justification; check for duplication or doctor shopping; communicate with the treating doctor; refer for pharmacy review if you can't justify the spend; implement monitoring to prevent recurrence.

The goal isn't to slash medication spend at the expense of outcomes. It's to ensure every medication is necessary, effective, and optimally dosed. That approach often reduces costs while improving claimant function and reducing long-term claim liability.