Health plans know that when patients take medications as prescribed, they are more likely to manage conditions effectively and stay out of the hospital.
If patients skip, stop or never start important drug therapies, they risk contributing to an estimated $500 billion in avoidable healthcare costs each year.1 The figure underscores why medication adherence is a high priority for health plans.
What Causes Medication Nonadherence?
Several factors can lead to prescriptions being abandoned, rationed, or stopped, but cost remains the primary influence.
- As health plans endure a 39% increase in average list prices for prescription medications since 2014,2 patients face more out-of-pocket costs due to higher deductibles, copays and coinsurance, as well as coverage restrictions or no coverage at all.3
- According to the recent CoverMyMeds Medication Access Report, 54% of patients surveyed are worried about the cost of their medications.4
- A 2024 IQVIA report claimed that “patients starting new therapy abandoned 98 million prescriptions at pharmacies with increasing frequency as costs rise,” even as the use of copay programs, e-coupons, and cash-pay increased.5
What Can Health Plans Do?
What if plans could get their arms around which members are nonadherent or at risk, specific prescriptions they aren’t filling, the out-of-pocket (OOP) cost to the member, as well as more affordable clinical or fulfillment alternatives they might have?
With accurate, reliable data in hand, plans can better dial in targeted member outreach efforts and interventions in support of better health outcomes and controlling costs.
- Prescription fill/refill behavior data can help to pre-emptively identify nonadherence before it becomes a significant issue.
- Filtering nonadherent or at-risk populations by medication can reveal how many members are noncompliant with certain drugs or types—e.g., anti-inflammatories—and to group affected members for targeted outreach.
- OOP cost per fill history can help determine the degree to which drug cost is a factor for nonadherent or at-risk members, and whether or how long OOP cost may be subject to a deductible.
- Available on-formulary alternatives can be referenced for cost comparison and discussed or suggested in member and prescriber outreach efforts.
Health plans can glean valuable strategic insights from prescription-level data. The right solution can help them turn insights into action.
Actionable Intelligence for Adherence
Whether lack of adherence is cost-associated or otherwise, tailored interventions like personalized communication and timely reminders are often deployed. Efforts typically focus on members managing multiple medications, especially those in Medicare Advantage plans with direct impact on Star ratings. However, actionable intelligence can help target intervention to any population segment or chronic condition.
The AdminRx platform from Rx Savings Solutions (RxSS) helps a health plan identify, engage and empower members at risk for nonadherence. In addition, robust tools and proactive support can enhance the plan’s adherence strategy:
- Adherence scoring to monitor compliance, proactively addressing issues before they affect health outcomes or Star measure compliance
- Medication alternative suggestions to help users educate members on cost-effective options
- Member lists filtered by specific medications and timeframes to support targeted engagement
Built-in member engagement programs generate a targeted, tailored message for any member with a lower-cost opportunity. Each tactic leverages more than a decade of historical engagement data to determine the optimal message, time and communication channel for success.
Health plans that leverage AdminRx can more effectively engage members and turn adherence challenges into educational opportunities. This proactive approach aids in improving Star ratings, reducing costs, and ensuring access to essential medications, fostering better health outcomes and member satisfaction.
Learn more about how health plans are using RxSS and AdminRx.
- National Library of Medicine; Cost of Prescription Drug-Related Morbidity and Mortality, 2018
- GoodRx; Tracking Prescription Out-of-Pocket Spending, accessed June 2025
- GoodRx; The Big Pinch: New Findings on Changing Insurance Coverage of Prescription Medications, accessed June 2025
- CoverMyMeds: Medication Access Report, 2023
- IQVIA; The Use of Medicines in the U.S. 2024: Usage and Spending Trends and Outlook to 2028, accessed June 2025
