Pharmacogenomics: A Clinical Strategy to Reform Utilization Management
Summary:
Pharmacogenomics is reshaping utilization management in workers’ compensation by replacing trial-and-error prescribing with clinically precise decision-making. By using genetic insight to guide medication selection and step therapy decisions upfront, PGx reduces authorization delays, avoids ineffective treatments, lowers complication risk, and supports faster, more cost-effective recovery for injured workers—while giving payers and PBMs a stronger clinical foundation for UM.
Modernizing Utilization Management Through Pharmacogenomics
Utilization management (UM) plays a critical role in ensuring safe, appropriate, and cost-effective‑ medication use in workers’ compensation. Many physicians report that PA delays negatively impact clinical outcomes, highlighting the need for a more modern and clinically guided approach [1]. Pharmacogenomics (PGx), the study of how genetics influence medication response, offers a way to refine UM by helping payers and treating clinicians make more precise and effective treatment decisions from the start.
1. Pharmacogenomics Strengthens UM and Helps Reduce Delays
Workers’ compensation cases are particularly vulnerable to treatment delays, as prolonged recovery can increase both medical and indemnity costs. PGx strengthens the UM process by introducing individualized clinical insight into medication selection. Instead of relying on trial-and-error methods, PGx enables evidence-based decisions that help determine whether a medication is likely to work for a specific patient. This can reduce authorization cycles and improve the speed at which injured workers receive appropriate therapy.
2. PGx Supports More Effective Step Therapy Decisions and Reduces Risk of Complications
Step therapy often requires workers to try a first line medication and show failure before switching to an alternative. PGx can prevent these ineffective trials by identifying when a drug is unlikely to work. For example, clopidogrel requires CYP2C19 activation, but individuals may carry variants that limit this process, increasing the risk of cardiovascular complications and reducing therapeutic benefit [2]. Traditional step therapy may still require a documented “failure,” even though clopidogrel was never a suitable option.
With PGx supported UM, a worker’s CYP2C19 genotype can justify bypassing these steps and approving the appropriate therapy immediately. This reduces administrative delays and helps prevent avoidable adverse events that could otherwise escalate a workers’ compensation claim through emergency care or prolonged treatment. By avoiding ineffective therapy trials up front, PGx helps keep recovery on track.
PGx can also support a more dynamic formulary by marking drugs as preferred or nonpreferred based on an individual’s genetic profile, aligning with value-based insurance design principles [3].
3. Pharmacists Are Key to Implementing PGx Enabled UM
As PGx becomes more integrated into clinical decision-making, pharmacists play a central role in interpreting genetic results and applying them to medication management. Within PBMs, pharmacists help develop the criteria and logic that support PGx-driven UM decisions. In clinical settings, they translate PGx findings into actionable recommendations and collaborate with prescribers to ensure safe and effective therapy choices. Their involvement aligns with research demonstrating that pharmacists are well positioned to deliver and interpret PGx testing services [4].
Moving Toward More Precise, Patient Centered UM
Pharmacogenomics does not replace utilization management—it enhances it by making decisions more individualized, evidence-based, and timely. PGx offers a practical way to reduce delays, avoid ineffective step therapies, and prevent avoidable complications that can extend recovery or escalate claim costs. By ensuring injured workers receive the right medication the first time, PGx helps support safer, faster, and more cost-effective recovery outcomes. As the field of pharmacy continues to evolve, PGx is becoming an important tool for strengthening the clinical foundation of UM across the workers’ compensation system [5].
Bottom Line
Utilization management delays are no longer just an administrative inconvenience—they are a material driver of prolonged recovery and rising claim costs. Pharmacogenomics brings clinical precision to a system built on general rules, replacing trial-and-error step therapy with data-backed decisions that work the first time.
For PBMs and payers, integrating PGx into utilization management is not a theoretical upgrade—it is a practical lever. It reduces friction, strengthens clinical credibility, lowers downstream costs, and helps injured workers recover and return to work faster.
By Martin Myers
PharmD Candidate (P4)
For questions, e-mail pharmd@prodigyrx.com
Citations
1. American Medical Association. (2022). 2022 AMA prior authorization (PA) physician survey.
2. Caudle, K. E., et al. (2022). Clinical Pharmacogenetics Implementation Consortium Guideline for CYP2C19 Genotype and Clopidogrel Therapy: 2022 Update. Clinical Pharmacology & Therapeutics, 112(2), 329–337.
3. Fendrick, A. M., et al. (2017). The impressive flexibility of value based insurance design. American Journal of Managed Care, 23(3), e93 e95.
4. Mills, R., & Haga, S. B. (2013). Clinical delivery of pharmacogenetic testing services: a meta analysis of pharmacists’ and patients’ experiences. Pharmacogenomics Journal, 13(5), 415 422.
5. Ratchford, A., et al. (2021). The Tipping Point of Pharmacogenomics in Pharmacy Practice. Journal of the American Pharmacists Association, 61(1), e88 e92