The ROI of Precision: Why Pharmacogenomics Makes Sense for Workers’ Comp and PBMs

Summary:

Pharmacogenomics improves medication effectiveness in workers’ compensation by replacing trial-and-error prescribing with genetically informed, clinically precise decision-making. By guiding drug selection and dosing upfront, PGx reduces failed therapies, avoids preventable adverse drug reactions, shortens recovery timelines, and lowers total claim costs—while enabling PBMs and payers to shift utilization management from reactive cost control to proactive, outcome-driven oversight.

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Prescription drugs are one of the biggest cost drivers in healthcare—and surprisingly often, they don’t work as intended. Many patients fail to respond to therapy or experience adverse drug reactions (ADRs) that slow recovery and raise costs. For pharmacy benefit managers (PBMs) and workers’ compensation insurers, this creates a familiar problem: rising pharmacy spend, prolonged disability, and inconsistent outcomes.

Pharmacogenomics (PGx) offers a smarter path forward. By using genetic information to guide medication selection, PGx helps ensure the right drug is prescribed the first time. In workers’ compensation, where faster recovery and return to‑ ‑work matter just as much as cost control, the value proposition is especially strong.

The Hidden Cost of Trial and Error Prescribing

In today’s system, prescribing is often a process of trial and error. Large real‑world studies show that 30–50% of patients do not respond to first‑line antidepressants, leading to medication changes, extra provider visits, and delayed recovery [1,2]. Each failed therapy adds cost—not just in pharmacy spend, but in extended disability time.

Adverse drug reactions compound the problem. Serious ADRs occur in roughly 6.7% of hospitalized patients and are a major cause of preventable morbidity [3]. For workers’ comp claims, ADR related‑ ER visits or hospitalizations can quickly derail recovery and escalate total claim costs. Workers’ compensation programs depend on safe, effective medication use to control claim duration and get injured employees back to work. PGx directly supports both goals.

Smarter Pain Management

Pain treatment sits at the center of many workers’ comp claims, yet genetic differences strongly influence how patients respond to common medications.

• Opioids:
  Genetic variation in the CYP2D6 enzyme affects how opioids like codeine and tramadol are activated. Some patients receive little pain relief, while others face higher toxicity risk—even at standard doses. Clinical guidelines recommend avoiding these medications in genetically at‑risk patients and choosing safer alternatives [4,5].

• NSAIDs:
  Variants in CYP2C9 reduce how quickly certain NSAIDs are cleared from the body, increasing the risk of gastrointestinal bleeding and other complications. PGx guided‑ prescribing allows clinicians to select safer options and avoid costly adverse events [6,7].

When medications work—and don’t cause side effects, patients heal faster. PGx guided‑ prescribing improves symptom control while minimizing complications, reducing disability duration and indemnity costs.

This benefit extends beyond pain. For example, PGx guided‑ treatment of depression has been shown to improve response and remission rates compared with standard care, supporting more stable recovery and work re‑entry after injury [8].

The PBM Advantage

PBMs are uniquely positioned to make pharmacogenomics actionable at scale. By integrating PGx into existing workflows, PBMs can shift from reactive cost control to proactive, precision‑based management.

Opportunities include:

• PGx‑informed formularies

• Targeted testing for high‑risk claims (such as new opioid prescriptions)

• Clinical pharmacist support to guide prescribers

• PGx‑enabled utilization management that flags high‑risk therapy early

This approach doesn’t just reduce pharmacy costs—it improves total claim outcomes.

Bottom Line

Pharmacogenomics isn’t experimental. It’s supported by clinical guidelines, real world evidence, and growing adoption across healthcare. In workers’ compensation, where medication effectiveness directly influences recovery time and total cost of care, PGx represents a high‑ ROI‑ investment.

For PBMs and workers’ comp insurers, the question is no longer whether pharmacogenomics belongs in pharmacy management, it’s how soon it can be implemented.

By Martin Myers

PharmD Candidate (P4)

For questions, e-mail pharmd@prodigyrx.com

Citations

1. Rush AJ, Trivedi MH, Wisniewski SR, et al. Acute and longer term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. American Journal of Psychiatry. 2006;163(11):1905–1917.

2. Trivedi MH, Rush AJ, Wisniewski SR, et al. Evaluation of outcomes with citalopram for depression using measurement based care in STAR*D: implications for clinical practice. American Journal of Psychiatry. 2006;163(1):28–40.

3. Lazarou J, Pomeranz BH, Corey PN. Incidence of adverse drug reactions in hospitalized patients: A meta analysis of prospective studies. JAMA. 1998;279(15):1200–1205.

4. Clinical Pharmacogenetics Implementation Consortium (CPIC). Guideline for CYP2D6, OPRM1, COMT and opioid therapy. 2020.

5. Del Tredici AL. Optimizing opioid therapy with pharmacogenetics. Practical Pain Management. 2021;21(2).

6. Lima JJ, Thomas CD, Barbarino J, et al. Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for CYP2C19 and Proton Pump Inhibitor Dosing. Clin Pharmacol Ther. 2021;109(6):1417-1423. doi:10.1002/cpt.2015.

7. Kathuria A, Roosan MR, Sharma A. CYP2C9 polymorphism and use of oral nonsteroidal anti inflammatory drugs. U.S. Pharmacist. 2021;46(3).

8. Bousman CA, Arandjelovic K, Mancuso SG, et al. Pharmacogenetic tests and depressive symptom remission: A meta analysis of randomized controlled trials. Psychiatry and Clinical Neurosciences. 2019;73(2):69–74.