CareReview / Solutions / Pharmacy Review
Intelligent Medication Review
Independent, pharmacist-led coverage determinations and appeals — built for the volumes PBMs and payers manage today.
Intelligent Medication Review
Independent, pharmacist-led coverage determinations and appeals — built for the volumes PBMs and payers manage today.
We help PBM and payer partners manage rising clinical review volumes with independent, timely, evidence-based determinations. Our technology-enabled process matches each case to the right clinical expertise, supporting appropriate medication use and operational efficiency.
Deeper clinical insight and streamlined review help our partners strengthen compliance and ensure members receive the right therapy at the right time.
Core Pharmacy Review Services
Coverage Determination Review
Each request is screened for complete documentation, then evaluated by a clinical pharmacist or physician against formulary criteria, clinical guidelines, and plan policy. Covers prior authorization, step therapy, and quantity-limit reviews, with peer-to-peer consultation available.
Pharmacy Appeal Review
Appealed determinations are reviewed by an independent, specialty-matched clinician with expertise in the therapy at issue, supporting accurate, defensible outcomes at every appeal level.
External Review
As a URAC-accredited IRO, CareReview issues final, impartial determinations on medication coverage disputes once internal appeals are complete.
Specialty & Advanced Pharmacy Services
Specialty Medication Review
Appropriate use of high-cost and complex therapies.
Compound Medication Review
Safety, efficacy, and regulatory compliance.
Fraud, Waste & Abuse Support
Detecting misuse and strengthening compliance.
Why CareReview for Pharmacy
- Genuine independence — CareReview is structurally separate from PBM internal decision-making, protecting neutrality and regulatory standing at a moment when plan sponsors and regulators are asking harder questions about who reviews a PBM's own denials.
- Pharmacist and physician reviewers spanning adult, geriatric, and pediatric specialties, including RPh and CPhT credentials.
- Built to absorb volume spikes from specialty drug growth without turnaround slippage.