The Rx to a Stale Medication Adherence Program

Ensuring members are willing and able to take their medicines as prescribed by their doctors (“medication adherence” in industry terms) is one of the top challenges at health plans, especially Medicare Advantage plans with prescription drug coverage.

The concern is well-founded. No matter your locus of concern—member health outcomes, cost containment through reducing adverse health events, or boosting Star ratings—medication adherence plays a critical role.

Why Medication Adherence Matters 

The good news is, these initiatives are well-aligned: making medication adherence easier benefits members and plans alike. For members living with chronic conditions, adherence to therapy leads to better clinical outcomes by reducing the likelihood of severe complications, such as cardiovascular events. Over time, it also supports improved quality of life through more consistent condition management. From a plan perspective, strong medication adherence in key therapeutic areas, especially for chronic conditions, has been repeatedly shown to lower medical costs. The converse is staggering: in the U.S., tens of billions of dollars in annual avoidable medical costs are attributable to medication non-adherence.

The Stars Opportunity 

Medication adherence is also a cornerstone of Star ratings performance: among Medicare Advantage plans that achieve 5 Stars on any of the three adherence measures for Diabetes, Hypertension, or Cholesterol medications, 85-90% also earn an overall 4 Star rating.

In a typical Stars measurement year, adherence measures are triple-weighted, accounting for roughly one-third of Part D Star ratings and up to 15% of overall Stars performance. However, for measurement year 2026, those triple weights have temporarily dropped to single weights, as CMS accommodates updates to  sociodemographic status (SDS) risk adjustment in the calculation methodology. 

So, what’s the move? 

Why Now Is the Right Time to Refresh Your Approach 

For plans that have been struggling with rising Star cut points (highly competitive on the adherence measures), or those hesitant to disrupt hard-earned progress on historically high-value measures, this is a rare window to reassess and strengthen adherence strategies with lower downside risk.  

Most members taking chronic care medications are able to maintain a threshold level of adherence with no intervention (for Stars medication classes, the measurement at 80% of Percentage, across therapies.) It’s often the remaining members that are the hardest to move, and these are the members to focus on. For these members, a one-size-fits-all approach is not going to drive behavior change.  

How Leading Plans Differentiate 

Across our client projects, several key trends are emerging among plans looking to boost Medicare Part D adherence programs: 

• In-sourcing is in. After a decade of handing the reins for medication management over to large-scale operations, plans are reversing course. While containing operational costs is important, stakeholders are realizing that large, generic outreach campaigns lack the personalization that motivates members. Many plans are launching agile internal teams, augmented with technology, to deliver a trustworthy, more connected member experience.
• First impressions matter more than ever. Members living with chronic conditions who are new to a health plan are often at higher risk for non-adherence. From the member perspective, the onboarding process can be overwhelming, confusing, or even worse—conflicting. Industry leaders are addressing this by providing clear, actionable instructions about drug coverage and medication access from the outset instead of leaving it up to the members to navigate the maze.
• Digital-forward strategies are no longer optional. Medicare plans that adopted the myth that “seniors don’t like technology” are now scrambling to catch up with competitors that invested proactively in digital engagement. If that sounds familiar, now is a good time to elevate your processes, leading your adherence program with digital outreaches or using them to facilitate connections with your knowledgeable in-house team. Or maybe you’re up for experimenting with an AI-based digital front door or outbound scheduling agents to help augment your care team, ensuring clinical resources stay focused on what they do best—providing expert care. 

Change Requires Careful Execution 

Any shift in processes can be disruptive to members, and this is especially true for members managing chronic conditions. Transitions should always be handled with the utmost care, compassion, and crucially, clear information and instructions. Never leave members guessing or forced to navigate complex benefit coordination on their own.  

Where to Start 

If your team isn’t sure where to begin, you’re not alone. Improving medication adherence requires coordination across strategy, operations, platforms and data, and program design. 

Engagys partners with plans to diagnose where adherence breaks down and to design practical, member‑centered solutions that drive measurable improvement. 

 Contact us today to start the conversation.