Medicare Advantage plan leaders know medication adherence matters. However, few have cracked the code on how to move the numbers, especially for the member populations that matter most under SDS risk adjustment.
This blog takes a closer look at what it actually takes to drive results. It is not just about effort. Most plans are already working hard. It is about having the right infrastructure, the right team, and the right approach to reach members when it counts.
Where Most Plans Start: Good Intentions, Wrong Tools
Many plans managing medication adherence today are doing so with a combination of internal teams, provider partnerships, and manual processes. In some cases, that means tracking members on spreadsheets with countless sheets and tabs.
The problem is not the people but rather the data and the infrastructure. Spreadsheets cannot ingest daily claims. They cannot flag a member the moment their first fill goes through. They cannot prioritize who to call first based on dual eligibility status, disability, or age.
Without that foundation, even a dedicated team will spend time calling the wrong members, missing critical outreach windows, and duplicating effort. The result is adherence rates that plateau, or worse, continue to decline.
The Data-Driven Platform Is Not Optional
The first requirement for moving adherence rates is a data-driven platform with AI-powered targeting and prioritization. What matters most is how the platform is built and what it does with data. Daily claims ingestion is essential. Members fill prescriptions around the clock.
A weekly or biweekly claims pull means your team is working from stale information. By the time an outreach call goes out, the member may have already filled their medication. That is wasted effort and unnecessary member friction.
Beyond ingestion speed, the platform must identify members at the moment of their first fill, not after they have been with the plan for 90 days. Members who fill 30-day supplies may have two or three fills before they even appear on a standard report. Catching them early is the difference between proactive outreach and reactive scrambling.
Prioritization matters just as much as targeting. Knowing who to call is straightforward. Knowing who to call first requires layering in sociodemographic factors: dual eligibility, disability status, age. These are the members who carry the most weight under SDS risk adjustment and face the most barriers to adherence. They need to move to the top of the queue.
Technology Gets You to the Door But Your Team Gets You Inside
A strong platform surfaces the right members at the right time. What happens next depends entirely on the quality of the care team making contact.
Pharmacy outreach is not the same as medical outreach. Claims are adjudicated in real time. When a member cannot get their medication at the pharmacy, the problem needs to be solved on the spot. That requires a team that understands prior authorization processes, formulary navigation, and how to work with local pharmacies and providers to remove barriers quickly.
Local knowledge is an underrated driver of results. Members in rural New Mexico face different challenges than members in urban Pennsylvania. The pharmacies are different. The provider relationships are different. The SDOH barriers are different. A care team that understands the local landscape builds the kind of trust that translates into members picking up the phone year after year.
Solving problems end to end matters too. Transferring a member to another team and closing the ticket is not the same as following up to make sure the issue was resolved. That follow-through is what builds lasting engagement.
What This Looks Like in Practice
Consider a 50,000-member Medicare Advantage plan that came to ActualMeds in 2025 after three consecutive years of low adherence performance. Forty percent of its membership was dual eligible. The plan had been relying on a mix of internal teams and provider partners.
Progress was lagging and they needed a new approach. That’s why the plan partnered with ActualMeds.
ActualMeds carved out 17,000 dual-eligible members for focused outreach. Using daily claims ingestion and AI-driven prioritization, the team reached 7,000 unique members across more than 27,000 outreach attempts, achieving a 70.4% unique member reach rate. Nearly 7,500 refills were facilitated.
The year-over-year adherence gains told the story. Overall rates improved 5% to 8% across diabetes, RASA, and statins. Within the dual-eligible population specifically, diabetes adherence rose 8%, RASA improved 4%, and statins climbed 5%. Those gains in the dual-eligible cohort lifted adherence rates across the entire plan population.
For members under age 55, the results were even more striking. Diabetes adherence improved 12% year over year. RASA and statins followed with 6% and 9% gains respectively.
These numbers are what becomes possible when the right platform and the right team work together on the right members.
If your plan is managing adherence with outdated tools or hitting a ceiling on results, there is a better path. Watch our on-demand webinar to go deeper on SDS risk adjustment and adherence strategy or connect with the ActualMeds team to talk through what is possible for your membership.
Watch the webinar on demand today.
