Clinical Reviews Are Essential to Providing Patient Safety

Clinical reviews are essential in administering an employer-sponsored prescription benefit program. All prescription benefit managers (PBMs) have some form of clinical review in place for their clients, and these programs are typically vetted through a PBM’s pharmacy and therapeutics committee. This committee, comprised of pharmacists and doctors who are both internal and external to the organization, meets periodically to evaluate whether drugs meet certain criteria to place them on a clinical review list. The most common components in this evaluation are (in no priority order): patient safety, off-label use, and cost. Critical to this evaluation is whether the drug can have dangerous side effects when combined with another medication. 

Adverse drug interactions are becoming anincreasingly prevalent problem. In HealthAffairs’ May 2019 article, “Solving Medication Overload: America’s Other Drug Problem,” the Lown Institute notes that, though more life-extending drugs have become available to the marketplace, individuals—especially those who are older—are at greater risk than ever of an adverse drug event. According to the Lown Institute, over 40% of adults take five or more medications and, when including over-the-countermeds and supplements as well, nearly 20% of older adults take 10+ medications. The unsupervised interaction of those substances can have devastating consequences: over 750 people age 65 and older are hospitalized every day for an adverse event from one or more medications.Additionalmedications increase a person’s risk of having an adverse reaction by 7 to 10%. 

As we become older and we take more medications, clinical reviews become more prevalent and necessary to avoid harmful drug-to-drug interactions. While it may at times be frustrating for the member, who has to wait for their prescriber(s) to provide necessary clinical information and sometimes lab results, the sole basis of these programs is to protect the safety and well-being of an employer’s members and dependents. 

What is often misunderstood from both the employer’s and members’ point of view is that the clinical review process does not reduce their benefits and isn’t intended to question a doctor’s or pharmacist’s competency or to delay a member from receiving their medication(s). Clinical reviews act as a safeguard to ensure that the medication(s) prescribed and dispensed to members are used: