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Automated drug reviews promise comp savings; industry cautious of AI - Business Insurance Skip to content Register for free Search Search Log In Risk Management Cyber Risks Pricing Trends Mergers & Acquisitions Technology Sponsored Content WSIA RISKWORLD Workers Comp & Safety Workers Comp Cost Control Pain Management Workplace Safety International EMEA Asia-Pacific Latin America People Events BI Intelligence Top 100 Agents & Brokers Best Places to Work 2025 Lists Directories Insurance Pricing BI Stock Index Magazine Current Issue Past Issues Subscribe Women to Watch ALL INsurance Resources Risk Perspectives Sponsored Content Webinars White Papers Risk Management Cyber Risks Pricing Trends Mergers & Acquisitions Technology Sponsored Content WSIA RISKWORLD Workers Comp & Safety Workers Comp Cost Control Pain Management Workplace Safety International EMEA Asia-Pacific Latin America People Events BI Intelligence Top 100 Agents & Brokers Best Places to Work 2025 Lists Directories Insurance Pricing BI Stock Index Magazine Current Issue Past Issues Subscribe Women to Watch ALL INsurance Resources Risk Perspectives Sponsored Content Webinars White Papers Risk Management Cyber Risks Pricing Trends Mergers & Acquisitions Technology Sponsored Content WSIA RISKWORLD Workers Comp & Safety Workers Comp Cost Control Pain Management Workplace Safety International EMEA Asia-Pacific Latin America People Events BI Intelligence Top 100 Agents & Brokers Best Places to Work 2025 Lists Directories Insurance Pricing BI Stock Index Magazine Current Issue Past Issues Subscribe Women to Watch ALL INsurance Resources Risk Perspectives Sponsored Content Webinars White Papers Risk Management Cyber Risks Pricing Trends Mergers & Acquisitions Technology Sponsored Content WSIA RISKWORLD Workers Comp & Safety Workers Comp Cost Control Pain Management Workplace Safety International EMEA Asia-Pacific Latin America People Events BI Intelligence Top 100 Agents & Brokers Best Places to Work 2025 Lists Directories Insurance Pricing BI Stock Index Magazine Current Issue Past Issues Subscribe Women to Watch ALL INsurance Resources Risk Perspectives Sponsored Content Webinars White Papers Automated drug reviews promise comp savings; industry cautious of AI by Louise Esola Workers Comp , Workers Comp Cost Control Arthur J. Gallagher & Co. , Sedgwick Aug 12, 2026 Automated prescription-review tools are helping workers compensation claims administrators identify high-priced drugs, flag polypharmacy risks and enforce clinical rules, but experts caution that the technology must not replace individualized review. The tools can screen prescriptions against formularies, treatment histories, state requirements and lists of excessively priced or low-value products. They can also flag duplicate therapies, drug interactions and high-dose opioids for clinical review. An Enlyte report released July 31 found that clients using integrated pharmacy benefit management, medical bill review and clinical decision-support capabilities reduced total pharmacy spending by 18.4%. Out-of-network prescriptions generated 58% of the savings despite representing a smaller share of prescription volume. Interventions involving so-called opportunistic products generated average savings of $915 per prescription, nearly four times the savings from other clinical interventions, Enlyte said. For clients using automated decision rules, 49% of opportunistic-product savings required no claims examiner intervention. Enlyte uses rules and clinical messages developed and maintained by pharmacists, not artificial intelligence, said Nikki Wilson, the company’s Omaha, Nebraska-based senior director of clinical pharmacy services. When a prescription requires prior authorization, the system gives the claims examiner a recommendation based on the client’s plan design, formulary, prescription history and applicable clinical and regulatory rules. Some clients authorize rules that automatically return an initial denial for products identified as high-cost and low-value, but examiners can overturn it, she said. “There’s a human in the loop always,” Ms. Wilson said. Opportunistic products include private-label topical analgesics containing ingredients available in less expensive products and convenience packs that combine existing drugs and supplies under a new product code, she added. At Gallagher Bassett Services, pharmacy benefit managers do not automatically decide drug authorizations, said Leah Sharp, Huntsville, Alabama-based senior vice president of GBCare and managed care. Clinical decision-support tools instead give resolution managers and clinical professionals real-time guidance based on state regulations, treatment guidelines, clinical evidence, health-risk scores and client rules, she said. AI is being used to summarize medical records, claim notes and treatment timelines, improving workflow without directing whether a drug should be approved or denied, she said. “It’s never going to replace the judgment call,” Ms. Sharp said. Prescription-screening tools can organize cases by severity and move potentially dangerous polypharmacy cases to the front of the review queue, said Andrew Newhouse, Rochester, Michigan-based director of clinical pharmacy at Sedgwick Claims Management Services. If a worker is taking multiple medications, the system can quickly identify possible interactions, duplicate therapy or other concerns and prompt a pharmacist or claims professional to review the entire file, he said. That is particularly important because one drug can increase or reduce the effect of another, making the overall regimen difficult to balance, he added. The technology does not change medications automatically, Mr. Newhouse said. A pharmacist can contact the prescriber, and any change remains a clinical decision. The routine substitution of an FDA-approved generic when a doctor has not required a brand-name drug is not an AI decision, he said. In terms of best serving injured workers, the claimant’s bar is skeptical of automation and appreciates safeguards, said Tiffany Speers, Oakland, California-based president of the California Applicants’ Attorneys Association and an attorney with Boxer Law. “Automation is the first step of summarization of information,” she said. “An actual person needs to analyze that to make a sound decision.” Related News Prison worker’s training injury comp claim, not constitutional seizure August 12, 2026 AI agent muscles into gym waitlist August 12, 2026 Maritime law bars consortium claim by seaman’s wife August 12, 2026 Business Insurance announces Women to Watch winners August 12, 2026 East Asian nations brace for historic typhoon season August 12, 2026 Insured cat losses hit six-year low: Swiss Re August 12, 2026 Extreme heat waves threaten businesses and infrastructure: Swiss Re August 12, 2026 Turkish insurers deliver as profits surge August 12, 2026 Typhoon threat disrupts hundreds of flights August 12, 2026 Facebook-f X-twitter Linkedin-in Business Insurance is a singular, authoritative news and information source for executives focused upon risk management, risk transfer and risk financing. 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