Making nonadherence a nonissue

At Prime, we're working to keep nonadherence numbers dow

July 17, 2019

About 50 percent of people in the United States don’t take their medicine as prescribed. For Medicare members, the number is slightly greater, at 55 percent.¹ And nonadherence costs between $100 and $300 billion.² That’s the annual amount of avoidable health care costs due to nonadherence in the United States.

Nonadherence takes a toll on chronic conditions

Nonadherence related to diabetes, heart failure and high blood pressure — three major health conditions for seniors — results in billions of dollars in Medicare fee-for-service expenses, millions of hospital days and thousands of ER visits that could have been avoided.³ If just 25 percent of nonadherent members with high blood pressure started taking their medicine, Medicare could save $13.7 billion annually and avoid over 100,000 ER visits.³

“Just do it” isn’t the right answer

The reasons for nonadherence vary with Medicare members:

  • Some think they’re fine and don’t need medicine
  • Others may have memory problems and forget to take a dose
  • Some members have bad side effects from their medicines and simply stop taking them as prescribed

Whatever the reason, these members aren’t staying on treatment. Which means they could end up back at their doctors’ office, or in urgent care or the ER. And those costs add up.

CMS measures drug adherence

Drug adherence is a key factor in Medicare Star ratings, which measure Medicare plan performance. The Centers for Medicare & Medicaid Services (CMS) monitors adherence in three categories: high blood pressure, high cholesterol and diabetes.

CMS measures adherence by “proportion of days covered” (PDC), with most conditions requiring a PDC of at least 80 percent. That means a person must have a supply of their medicine at least 80 percent of the time to be considered adherent.

Prime checks all the Medicare boxes — and more

At Prime Therapeutics (Prime), we help people get the medicine they need to feel better and live well. Our GuidedHealth® program monitors and helps improve adherence in all three CMS categories — plus asthma, depression, schizophrenia and chronic obstructive pulmonary disease (COPD).

GuidedHealth analyzes pharmacy and medical data to help improve health outcomes. It offers a basic adherence report that shows PDC data for members taking medicine for chronic conditions. Or clients can choose our advanced Smart Data adherence report. It includes PDC data, and also uses our proprietary model to predict if a member is likely to stick to their treatment or not.

We also offer a Missed Refill program that identifies members who don’t refill their prescriptions. The members are called to see if they have any issues. Then, if they haven’t refilled their prescription in the next week, they’re contacted again as a reminder.

Our programs get results — for example, 73.8% greater adherence rates

A recent study on our Missed Refill program monitored members taking medicines for high cholesterol, diabetes and high blood pressure. The intervention group showed a 73.8 percent higher refill rate than the control group.4

Prime is committed to giving our Medicare clients and members the best service possible. In fact, products like GuidedHealth and our Missed Refill program help boost Star ratings for our health plan clients.


  1. Top 6 Problems with Medication Adherence in Seniors. (April 25, 2019). Retrieved June 11, 2019, from https://www.agingcare.com/articles/medication-problems-elderly-people-have-146111.htm
  2. IMS Study: Inappropriate Medication Use Costs More Than $200 Billion Per Year. (July 16, 2013). Retrieved June 11, 2019, from https://www.pharmacytimes.com/publications/issue/2013/july2013/ims-study-inappropriate-medication-use-costs-more-than-200-billion-per-year
  3. Lloyd, JT, et al. (March, 2019). How Much Does Medication Nonadherence Cost the Medicare Fee-for-Service Program? – PubMed – NCBI. Retrieved June 11, 2019, from https://www.ncbi.nlm.nih.gov/pubmed/30676355
  4. Prime internal data.

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