Why this reading matters
The video introduced the landscape you are working in: many schemes, a cast of people with different needs, funding that fragments the records, a test you inform but do not decide, and a window where your work matters most. This reading fills in the detail. It sets out how the schemes differ, what each person on a claim needs from you, how medication funding changes what you can see, how to write about "reasonable and necessary" without overstepping, and how timing changes what a review can achieve. It ends with a worked example and the mistakes we most often see from pharmacists new to the work.
IMM built this material for our own pharmacists. The aim is the same here: a reviewer who understands the scheme context produces a report that is used. A reviewer who does not, however good their pharmacology, produces a report that sits in a file.
Why pharmacists need scheme training
Doctors who perform independent medical examinations in personal injury schemes typically complete scheme-specific training, for example permanent impairment assessor training in some jurisdictions. Allied health practitioners treating claimants are expected to understand the scheme's rules and forms, and some schemes run training for them. Pharmacists reviewing medication on claims have had no equivalent.
That gap shows. The common failures in pharmacist reports on claims are rarely pharmacological. They are contextual:
- Answering a question that was not asked, while missing the one that was.
- Writing as if the reviewer were the treating clinician ("cease the diazepam").
- Making legal findings ("not reasonable and necessary") rather than giving clinical evidence.
- Not knowing which records exist, so the history is incomplete.
- Not understanding where the claim is in its life, so recommendations are mistimed.
Each of these is fixable with training. That is what this course is for.
The schemes at a glance
Australia has no single personal injury scheme. The table below is a simplified map. It is deliberately general: details, names and rules differ between jurisdictions and change over time, so always check your scheme's rules.
| Scheme type | Who it covers | Typical medication questions |
|---|---|---|
| State and territory workers' compensation | Workers injured at work, under each state or territory's scheme | Is the medication for the accepted injury? Is it helping? Is it affecting capacity and return to work? Is a new symptom a medication effect? |
| Comcare | Commonwealth employees and employees of some licensed self-insurers | As for workers' compensation, under the Commonwealth framework |
| Compulsory third party (CTP) | People injured in motor vehicle accidents | Statutory benefits for treatment, often with long tails; medication review in chronic pain and psychological injury; questions that may feed into settlement |
| Lifetime care schemes | People with the most severe injuries (for example, serious brain or spinal cord injury), depending on the jurisdiction | Long-term, complex regimens; polypharmacy; behaviour and sedation; carers administering medicines |
| NDIS | People with permanent and significant disability | The NDIS generally does not fund medicines, but medication affects function, supports and behaviour support plans |
A few points worth knowing at the outset:
Scheme agents and self-insurers. In some schemes the claim is managed by a scheme agent on behalf of a government-owned insurer. In others, licensed insurers or self-insurers manage claims directly. Your referrer may be any of these. Ask who the decision-maker is, because it affects who receives your report.
Statutory benefits and common law. Some schemes provide ongoing benefits (weekly payments and treatment) and separately allow a claim for damages in certain circumstances. Medication evidence may be relevant to both. You do not need to understand the legal mechanics, but you should know that your report may be read by lawyers and may be tested.
NDIS and restrictive practices. On NDIS matters, medication is relevant when it affects a participant's function or behaviour. Where a medicine is used primarily to influence behaviour, it may be a regulated restrictive practice (chemical restraint) under the NDIS rules, with specific authorisation and reporting requirements. If you are asked to review on an NDIS matter, check the current NDIS Quality and Safeguards Commission requirements.
Who is who on a claim
Every person on a claim reads your report through their own lens. Knowing those lenses is the difference between a report that is used and one that is filed.
| Role | What they do | What they need from you |
|---|---|---|
| Insurer or scheme agent | Manages the claim, makes liability and funding decisions | Clear answers to the referral questions; evidence they can rely on |
| Case manager (claims officer, injury management advisor) | Day-to-day management of the file; usually your referrer | Plain-language findings; actions they can take this week; questions to put to others |
| Rehabilitation provider | Supports return to work, liaises with employer and treaters | Practical information on medication and function, sedation, safety-critical tasks |
| Treating practitioner (usually a GP) | Holds the treating relationship, prescribes | Respectful, evidence-based observations and options they can act on |
| Specialist prescribers | Pain specialists, psychiatrists, surgeons | The full picture, including medicines from other prescribers |
| IME | Examines the claimant; gives an independent medical opinion | Well-framed medication questions and an accurate history |
| Claimant | The person at the centre of the claim | To be treated fairly, with their information handled properly |
| Lawyers (either side) | Represent the claimant or the insurer | A report that is factual, balanced and defensible |
| You, the pharmacist reviewer | Independent review of the medication evidence | A clear referral, the records, and the authority to obtain more |
Two of these relationships deserve emphasis.
The case manager is your client, not your clinician colleague. They are skilled at managing claims, but they are not clinicians. Your report must translate clinical findings into practical actions. "Moderate anticholinergic burden" means nothing to most case managers. "Several of these medicines can cause drowsiness and slowed thinking, and together they may explain the rehab provider's observations" does.
The treating practitioner is the person who acts. In IMM's experience, 81% of recommendations are implemented by the treating prescriber when they are framed well. Everything about how you write should make it easy for a busy GP to say yes. Module 6 covers this in detail.
How medication is funded on a claim
Pharmacists often assume that a medicine on a claim is simply "paid by the insurer". The reality is messier, and it matters because the funding route determines which records will show the medicine.
The main routes
- PBS dispensing, reimbursed by the scheme. The medicine is dispensed under the PBS. The claimant pays the co-payment and claims it back, or the pharmacy invoices the co-payment to the insurer.
- Private dispensing, invoiced to the scheme. The medicine is dispensed as a private (non-PBS) prescription and the full price is invoiced to the insurer.
- Paid by the claimant and not claimed. The claimant pays and never claims it, sometimes because the medicine is for an unrelated condition, sometimes simply because they did not know they could.
- Unapproved and specialty products. Medicinal cannabis (mostly unapproved products accessed through TGA pathways), compounded preparations and some imported products are not PBS-listed. They may be paid privately, invoiced to the insurer, or the subject of a specific funding request.
- Over-the-counter medicines. Codeine-free analgesics, antihistamines, supplements and sleep aids bought without a prescription rarely appear in any record.
Practice varies between schemes, pharmacies and medicines. Some schemes expect PBS-listed medicines to be dispensed through the PBS where appropriate, with private dispensing for justified exceptions. Some Commonwealth benefits paid in relation to a compensable injury may also be subject to recovery arrangements. Check your scheme's rules rather than assuming.
What this means for the records
| Record | Will show | Will miss |
|---|---|---|
| PBS claims history (Services Australia, with consent) | PBS-subsidised medicines, prescriber, date, quantity | Private prescriptions, most medicinal cannabis, OTC medicines, hospital-supplied medicines |
| Insurer payment data | Medicines invoiced to the claim | Medicines the claimant paid for, PBS items not claimed, unrelated medicines |
| Pharmacy dispensing history | Everything dispensed at that pharmacy, PBS and private | Anything dispensed at other pharmacies |
| RTPM (via an authorised clinician) | Monitored medicines across all pharmacies in the system | Unmonitored medicines; anything outside the system |
| Prescriber correspondence | What that prescriber intends | What other prescribers have done; what was actually dispensed |
| Claimant interview | What the person actually takes, including OTC and cannabis | Accurate names, strengths and dates, especially when recall is affected |
The lesson is simple: no single source is complete. Module 4 shows you how to reconcile them.
"Reasonable and necessary" and medication
Most schemes fund treatment that meets a defined test. "Reasonable and necessary" is common. Some schemes use "reasonably necessary" or other wording, and the difference can matter legally. Tests are also amended from time to time. Check your scheme's rules for the exact test and any guidance the regulator has issued on how it is applied.
The clinical questions behind the test
Whatever the wording, these tests tend to ask a similar set of questions. The pharmacist's contribution maps onto them directly.
| The question behind the test | Your clinical evidence |
|---|---|
| Is the treatment appropriate for the accepted injury? | Indication; whether the medicine matches the injury and the presenting problem |
| Is it effective for this person? | Documented benefit: pain scores, function, sleep, return to work progress, claimant report |
| Is it consistent with accepted practice? | Consistency with current Australian guidance (for example, Therapeutic Guidelines, RACGP guidance on drugs of dependence, specialist college guidance) |
| Are there safer or more effective alternatives? | Pharmacological and non-pharmacological options |
| Is the benefit worth the cost and risk? | Adverse effects, interaction risk, dependence risk, monitoring burden, cost |
Where your role stops
You inform the decision. The insurer makes it. That distinction protects you, the claimant and the defensibility of the report.
- Write: "On the information available, there is no documented benefit from pregabalin since it was commenced at week 6. Pain scores and function have not improved, and the claimant reports dizziness. Current Australian guidance does not support pregabalin for non-neuropathic low back pain. The clinical evidence does not support continuing it in its current form."
- Do not write: "Pregabalin is not reasonable and necessary and the insurer should stop paying for it."
The first is a clinical opinion with its reasons. The second is a legal finding and a funding instruction. A lawyer will rightly ask whether you are qualified to make it.
Medicines for unrelated conditions
You will often see medicines for conditions the scheme does not cover: antihypertensives, a long-standing antidepressant, diabetes medicines. They still matter. They interact with claim medicines, they contribute to adverse effects, and changes to them can explain new symptoms. Include them in your history and your analysis, and say clearly that they relate to a non-claim condition. Whether the scheme funds them is not your question.
The points in a claim's life where review adds most value
Pharmacist review can help at any time, but its value is not evenly spread. IMM's experience, consistent with what is known about the transition from acute to chronic pain and the development of dependence, points to four key points.
| Point | What is usually happening | What pharmacist review can do |
|---|---|---|
| Weeks 4 to 12 | Early medicines have worked or not; patterns are forming; doses may be climbing | Catch escalation early; recommend a plan and expected duration before habits set; this is the best window |
| Week 12 | Acute pain should be resolving; acute-phase opioids should be ending | Ask why acute-phase medicines continue; check for a documented plan |
| Week 26 | Regimens are often complex; medicines added to manage the effects of earlier ones; secondary condition requests appear | Untangle prescribing cascades; separate medication effects from new conditions before they are investigated |
| Week 52 | Dependence and entrenched patterns are common; claims often reach significant decision points | Structured deprescribing plans; evidence for scheme decisions; IME questions |
Two practical points follow.
If you are referred late, say so. A week 60 referral can still achieve a great deal, but the plan will need to be slower and the expected outcomes more modest. Saying this in the report manages expectations and protects the credibility of the recommendation.
Recommend the next review point. Every report should state when the medication picture should next be checked and what should trigger an earlier look. This is how pharmacist review becomes part of claim management, not a one-off event.
A worked example
This example is invented and de-identified.
"Ms R", 38, aged care worker, injured her lower back transferring a resident. Workers' compensation claim accepted. Referred at week 9 with the question: "Please review current medications and advise whether they are appropriate."
What the pharmacist found:
- Week 1: paracetamol and ibuprofen; oxycodone 5 mg immediate-release, 20 tablets.
- Week 3: further oxycodone 5 mg, 20 tablets, from an after-hours clinic.
- Week 5: tapentadol slow-release 50 mg twice daily started by the GP; oxycodone continued "for breakthrough".
- Week 7: pregabalin 75 mg twice daily added for "leg pain". No neurological findings are documented.
- Claimant interview: she has not returned to work, sleeps poorly, feels "foggy" in the mornings, and is worried about driving to work.
How the scheme context shaped the review:
- Scheme and timing. Week 9 sits in the best window. The regimen is three months from becoming entrenched.
- Funding. The after-hours oxycodone was dispensed under the PBS at a different pharmacy and did not appear in the insurer's payment data. It was found only in the PBS claims history obtained with consent.
- The real question. "Are they appropriate?" is vague. After a call with the case manager, the pharmacist confirmed the underlying concern was the stalled return to work and whether the medicines were contributing. The report was framed around that (Module 3 covers this skill).
- Reasonable and necessary. The report set out the indication, documented benefit, guideline consistency, risks and alternatives for each medicine, and stated a clinical opinion. It left the funding decision to the insurer.
- Next review point. The report recommended a check at week 12 against the GP's response and a further review at week 26 if the regimen had not simplified.
Common mistakes
Assuming one scheme's rules apply everywhere. They do not. Check the scheme, every time.
Treating the case manager as a clinician. Translate your findings. Lead with what it means and what to do.
Relying on a single funding record. The PBS history and the insurer's payment data each miss things. Build from several sources.
Making the funding decision. Give the clinical evidence and your opinion. Leave the decision to the insurer.
Ignoring non-claim medicines. They interact and they confound. Include them and label them.
Forgetting the clock. A recommendation that would be ideal at week 8 may be unrealistic at week 80. Fit the plan to the stage of the claim, and always recommend the next review point.
Key points
- Pharmacists reviewing claims have had no scheme training. Most failures are contextual, not pharmacological.
- Australia has many schemes: state and territory workers' compensation, Comcare, CTP, lifetime care and the NDIS. Check your scheme's rules.
- Know who reads your report and what each needs: insurer, case manager, rehab provider, treating practitioner, IME, claimant and lawyers.
- Funding routes (PBS, private invoiced to the scheme, claimant-paid, unapproved products, OTC) determine what each record shows. No single source is complete.
- "Reasonable and necessary" (or your scheme's equivalent) asks about appropriateness, individual benefit, accepted practice, alternatives, and cost and risk. You give the evidence. The insurer decides.
- Weeks 4 to 12 are the best window. Weeks 12, 26 and 52 are key review points. Fit recommendations to the stage of the claim and always set the next review point.