What is a Section 19 pharmacy review?
Understanding NSW workers compensation pharmacy review requirements
Published 2026-04-03
If you manage workers compensation claims in NSW, you've likely heard about Section 19 pharmacy reviews. It's a specific requirement under NSW workers compensation law that applies to certain claims. Understanding what it is and when you need to arrange one is essential for compliance and optimal claims management.
What is Section 19?
Section 19 of the Workers Compensation Act 1987 (NSW) gives the statutory body regulating workers compensation the authority to request independent reviews of medication prescribed in workers compensation claims. A Section 19 request triggers an independent pharmacy review of the claimant's medications.
In practice, Section 19 reviews are typically arranged when:
- There are questions about medication appropriateness or necessity
- Medication costs are escalating significantly
- There's dispute about whether medication is claim-related
- Medication might be preventing recovery or causing incapacity
- The claim has been running for extended period with high medication costs
Key characteristics of Section 19 reviews
Independence: The pharmacy review must be conducted by an independent pharmacist not involved in the claim. The pharmacist has no stake in the outcome.
Expertise: The pharmacist must be qualified to assess medication appropriateness in the context of workers compensation claims.
Comprehensiveness: The review must address all medications the claimant is taking, assess appropriateness, necessity, and interactions.
Defensibility: The review must be rigorous and evidence-based. It's often used in disputes and must withstand legal scrutiny.
Claimant participation: The claimant usually participates in the review, providing history of medications, their perception of benefits and side effects, and goals for treatment.
How Section 19 reviews work in practice
The process typically follows these steps:
Request is made
Either the insurer or regulatory body requests a Section 19 pharmacy review.
Pharmacist is appointed
An independent, accredited pharmacist is identified to conduct the review.
Claimant is notified
The claimant is informed a review is being conducted and provided information about the process and pharmacist.
Assessment occurs
The pharmacist reviews medical records, obtains medication history, and often conducts a consultation with the claimant (by interview or phone).
Report is prepared
The pharmacist provides a detailed report assessing medications, their appropriateness, necessity, interactions, and recommendations for modification.
Findings are shared
The report is provided to the insurer, claimant, and treating providers. All parties review the pharmacist's findings and recommendations.
Timing and timeframes
Section 19 reviews typically take 4-8 weeks from initiation to completed report, depending on complexity and pharmacist availability. The claimant needs reasonable notice to prepare for any assessment appointment.
While a review is pending, medications usually continue at current regimen unless urgent safety concerns emerge.
Cost responsibility
In NSW workers compensation, the insurer typically funds Section 19 reviews as a claims management cost. The review is part of appropriate claims management, and costs are generally covered by the workers compensation scheme.
Using Section 19 findings
Once the pharmacist's report is received, it becomes part of the claims file and informs medication management decisions going forward:
- Medication changes: If the pharmacist recommends medication modifications, the insurer works with the treating provider to implement changes
- Dispute resolution: If medication appropriateness was disputed, the pharmacist's report provides expert opinion that informs the resolution
- Cost justification: If medication costs are high, the report documents whether costs are justified or whether cost reduction is possible
- Future prescribing: The report informs the insurer's position on future medication decisions in that claim
Outcomes of Section 19 reviews
Common outcomes include:
- Confirmation that current medications are appropriate and necessary (no change recommended)
- Dose adjustments to optimize benefit while reducing side effects
- Substitution of medications for more appropriate alternatives
- Discontinuation of medications no longer beneficial
- Recommendations for additional monitoring or follow-up assessment
- Identification of medication interactions requiring management
Compliance and best practice
If you manage NSW workers compensation claims:
- Know when Section 19 is appropriate: Understand your scheme's guidelines or regulatory direction on when to initiate Section 19 reviews
- Use accredited pharmacists: Ensure the pharmacist has experience with workers compensation and accreditation from relevant bodies
- Provide complete information: Give the pharmacist all relevant medical records and medication history to enable thorough assessment
- Act on findings: Don't arrange a Section 19 review and then ignore findings. Implement recommendations in consultation with treating providers
- Monitor outcomes: Track whether medication changes recommended by the pharmacist are being implemented and are improving outcomes
Claimant perspective
Some claimants view Section 19 reviews defensively, worrying that the review is designed to cut their medications or deny them support. Explain the review's purpose clearly:
"We're arranging a specialist medication review to ensure your medications are appropriate and supporting your recovery. The pharmacist will assess whether current medications are helping, whether side effects are a concern, and whether adjustments might improve your outcomes."
Claimants who understand the review is about optimizing their recovery are more likely to engage constructively.
Do you need a Section 19 pharmacy review for your NSW claim?
IMM provides Section 19-compliant pharmacy reviews for NSW workers compensation. Expert assessment, thorough analysis, and defensible recommendations. Let's ensure your medication review meets statutory requirements and supports optimal outcomes.
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