Pharmacy review pilot program: how to get started
Prove value with a focused pilot before full-scale rollout
Published 2026-04-03
Pharmacy review sounds promising, but you're hesitant to commit to full implementation without evidence it works in your environment. That's smart. A pilot program is the perfect way to test the approach, measure results, and build internal support before scaling across your organization.
Let's walk through how to design and execute a pharmacy review pilot that gives you clear evidence of value.
Why pilot pharmacy review?
Pilots serve multiple purposes:
- Test feasibility: Can you actually implement pharmacy review given your systems, processes, and team? What barriers emerge?
- Measure outcomes: Does pharmacy review actually improve outcomes for your claims? Cost reduction, faster resolution, better function?
- Calculate ROI: What's the actual return on investment? Are you saving more than you're spending on pharmacy reviews?
- Build support: When results are positive, you can show skeptics in your organization the evidence. It's easier to get buy-in for full implementation with pilot data.
- Refine process: Learn what works and doesn't in your environment. Use pilot experience to improve your processes before scaling.
Designing your pilot
A good pilot is focused, measurable, and realistic. Here's the structure:
Define scope
Decide what you're testing. Will you pilot across your entire portfolio, or specific claim types? Will all claims in the pilot get pharmacy review, or only those meeting certain criteria? Scope affects how many reviews you'll conduct and what resources you'll need.
Set duration
How long will the pilot run? 3 months is too short to see meaningful outcome changes. 6-12 months is typical. You need time for claims to progress, medication changes to be implemented, and outcomes to be measured.
Identify comparator group
To measure whether pharmacy review is making a difference, you need comparison. This might be: a similar set of claims NOT receiving pharmacy review, or pre-pilot historical claims from your portfolio. Comparator group shows what outcomes look like without intervention.
Define metrics
What will you measure to determine success? Cost, duration, claimant function, return to work, medication changes, provider engagement. Decide metrics before starting pilot so you know what data to collect.
Allocate resources
Who manages the pilot? Who refers cases? Who tracks outcomes? Designate pilot lead with clear responsibility for execution and success.
Pilot scope options
Consider which approach fits your organization:
Full portfolio pilot: All claims in your portfolio are eligible for pharmacy review during pilot period. Benefit: real-world test across all claim types. Drawback: high volume, complex execution.
Claim type pilot: Test pharmacy review on specific claim types. For example, all workers comp claims with injury date in a certain period, or all claims with medication costs exceeding threshold. Benefit: manageable scope, targeted learning. Drawback: results may not generalize to other claim types.
Team or office pilot: If you have multiple offices or teams, run pilot through one team. Benefit: focused execution with fewer stakeholders. Drawback: team-specific dynamics might not reflect organization-wide results.
Opt-in pilot: Offer pharmacy review as optional service to claims managers who want to try it. Benefit: builds enthusiasm among interested practitioners. Drawback: self-selection bias means results may be better than typical adoption would achieve.
Most effective pilots combine focused scope (specific claim types or conditions) with clear execution plan across the entire population meeting those criteria.
Pilot execution checklist
Before launching, confirm you have these elements in place:
- Clear pilot start and end dates
- Designated pilot lead with responsibility for execution
- Referral criteria documented and communicated to team
- Pharmacy review provider selected and contracted
- Process for referring cases defined (forms, submission method, contact person)
- Baseline data collected for comparator group (cost, duration, outcomes)
- Process for implementing recommendations defined
- Metrics and data collection process established (how will you measure outcomes?)
- Team trained on pharmacy review, referral criteria, and process
- Key stakeholders informed of pilot and its purpose
Running the pilot
During pilot execution:
- Track referrals: How many cases meet pilot criteria? How many are referred for pharmacy review? Why aren't some eligible cases being referred?
- Monitor turnaround: Are you getting reports back in promised timeframe? Are delays occurring? What's causing them?
- Measure implementation: When pharmacy review recommends medication changes, are changes being implemented? What barriers exist to implementation?
- Gather feedback: What do claims managers think about pharmacy review? Is it useful? What could improve?
- Track early outcomes: Are reviewed cases showing early signs of improvement (faster provider response, medication changes, claimant function)?
Regular monitoring helps you troubleshoot problems early rather than discovering issues only at pilot end.
Data collection and analysis
At pilot end, analyze results against your defined metrics:
Cost impact: Compare total claim costs for pharmacy review cases versus comparator group. Did medication optimization reduce costs? By how much?
Duration impact: Are claims receiving pharmacy review resolving faster? What's the average duration difference?
Function improvement: Do claimants receiving pharmacy review report improved function or fewer medication-related side effects?
Return to work: Are claimants receiving pharmacy review returning to work faster or with better outcomes?
Medication changes: What medications were changed based on pharmacy review recommendations? What types of changes were most common?
Provider engagement: Did treating providers engage with pharmacist recommendations? Were medication changes implemented?
ROI calculation: For every dollar spent on pharmacy reviews, what was the cost saving or outcome improvement?
Strong pilot data shows positive outcomes across multiple metrics. Weak results suggest pharmacy review approach might not work in your environment, or that process needs refinement.
Common pilot lessons
Organizations that run pharmacy review pilots typically learn:
- Implementation matters: Pharmacist recommendations are valuable only if they're actually implemented. Focus on addressing barriers to implementation.
- Provider relationships key: Treating providers who understand and engage with pharmacy recommendations are more likely to implement changes.
- Team training essential: Claims managers who understand pharmacy review and medication issues are more likely to use it effectively.
- Clear referral criteria critical: When referral criteria are ambiguous, inconsistent referrals result. Clear criteria lead to more consistent application.
- Measurement is powerful: Tracking outcomes shows where pharmacy review is working and where it's not. Data enables you to optimize your approach.
Scaling based on pilot results
If pilot is successful, how do you scale?
Formalize the process
Take what worked in the pilot and document it as your standard process. Create referral forms, documentation, tracking systems. Make pharmacy review a standard part of how you manage claims.
Expand scope gradually
If you piloted with specific claim types, expand to other types. If you piloted with one team, expand to others. Gradual expansion allows you to manage growth and refine process.
Invest in capability
Train additional team members on pharmacy review process and medication management. As you scale, your team needs to be able to consistently identify and refer appropriate cases.
Build systems
Integrate pharmacy review into your claims management systems. Automate referral where possible, track referrals and outcomes, generate reporting. System integration makes scaling feasible.
Monitor ongoing performance
Continue measuring outcomes at scale. Are results as good as pilot? Are there patterns you should adjust process for? Use ongoing data to continuously improve.
If pilot doesn't show positive results
What if pharmacy review doesn't improve outcomes in your pilot? Before abandoning the approach, consider:
- Was implementation robust? Were recommendations actually being implemented, or were they ignored?
- Was scope appropriate? Were you reviewing the right cases? Maybe certain claim types benefit more than others.
- Was provider engagement strong? Did treating providers engage with recommendations, or were they dismissive?
- Was pilot duration sufficient? Did you give enough time for changes to be implemented and outcomes to show?
- Was pharmacist quality appropriate? Did your pharmacy review provider understand insurance claims context and deliver quality work?
Often, weak pilot results point to execution or process issues rather than fundamental failure of approach. Consider refining and retrying before concluding pharmacy review doesn't work for you.
Ready to launch a pharmacy review pilot?
IMM helps organizations design and execute pharmacy review pilots. Let's develop a pilot plan, support your execution, and measure results to guide full implementation.
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