Adherence Starts Before the First Fill

In 2023, 98 million new therapy prescriptions were abandoned in the US. That number alone reframes how the industry should think about adherence.

The instinct, looking at a number that big, is to assume cost. And cost is real. But IQVIA’s data shows something more interesting underneath it. Of those 98 million abandoned prescriptions, 44 million were abandoned even when the patient’s out-of-pocket cost was under $10. That includes prescriptions that cost nothing.

44 million people, in a single year, walked away from a medication their doctor had just prescribed for them, and money was not the deciding factor.

That number is what the leading patient marketers in the industry have been pointing at for the last few years. The question is not only how to keep patients adherent once they start a therapy. The question is how a patient arrives at the pharmacy ready to start in the first place. By the time a prescription is written, the patient has already made dozens of decisions about whether the therapy is worth pursuing, whether they trust the diagnosis, whether they understand what the medication is for, and whether they believe it will help. Adherence is the cumulative result of those decisions. It starts well before the first fill.

The data underneath the headline

Non-adherence is one of the most expensive problems in US healthcare. Pharmaceutical Commerce’s 2026 roundtable cited estimates that medication non-adherence costs the US health system upward of $528 billion annually, contributes to roughly 1 in 10 hospitalizations, and is associated with approximately 125,000 deaths each year.

The launch-stage numbers are even sharper. Across 99 novel medicines launched in the US between 2020 and 2024, an average of only 35% of first-year prescriptions were actually filled. Forty-nine percent were rejected by payers. Seventeen percent were abandoned after payer approval. The standard playbook treats those as access problems, and many of them are. But sitting alongside them is the behavioral reality that millions of patients drop off the path to treatment for reasons that have nothing to do with the payer or the pharmacy counter.

The 2024 a:care Congress framed it directly: adherence is a behavior. Behaviors are formed long before the moment they show up at the pharmacy. The brands that are improving adherence outcomes today are the ones treating that behavioral truth as a brand strategy question, not a patient services question.

What changes when adherence is treated as a pre-fill question

Patient marketing teams that move adherence work upstream of the first fill operate from a different premise. The brand’s job is not only to be the medication a patient takes. The brand’s job is to be the source the patient trusts during the moments that determine whether they will take it at all.

Practically, that shifts where the investment goes.

Pre-diagnosis disease education matters more than it used to

A patient who arrives at their diagnosis already understanding the condition responds differently to a prescription than a patient who is hearing the diagnosis for the first time. Disease state education delivered through unbranded channels in the months and years before a patient is even diagnosed is the foundation of pre-fill adherence. It is not promotional work. It is the work of making sure that when the diagnosis comes, the patient has language for what is happening to them and a framework for what comes next.

Post-diagnosis onboarding shapes whether the first fill ever happens

The window between diagnosis and first fill is where the largest behavioral decisions get made. The patient leaves the appointment with a prescription in hand, a head full of new information, and a decision to make. Brands that win adherence in this window invest in materials specifically designed for that 24-to-72-hour period. Plain-language explainers, expectation-setting content, questions to bring back to the prescriber, and patient stories that make the experience of starting therapy feel less isolating. The work is not flashy. It is what makes the difference between the prescription getting filled and the prescription joining the 44 million.

HCP-patient communication tools change what happens inside the appointment

The 11-minute appointment is where pre-fill adherence either gets set up or undermined. Tools that help HCPs explain a therapy in language a patient can actually retain, shared decision-making aids that make the patient feel like part of the choice, and conversation guides that help the prescriber identify and address concerns in real time all shape what the patient does after they walk out the door. Brand teams that invest in these tools as adherence interventions, rather than only as HCP marketing assets, are doing something the rest of the industry has not yet caught up to.

Health literacy is an adherence intervention

If a patient cannot understand the materials they were given about their therapy, the probability they take it as directed drops sharply. We have written before about designing for health literacy across pharma marketing. The same principles apply with even higher stakes when the content is the patient education material that surrounds a first fill. Plain language, visual hierarchy, comprehension testing, and the discipline of designing for the reader’s actual cognitive context turn out to be among the most direct adherence interventions a brand can make.

Patient journey mapping with patients, not just for them

The journey from symptom to diagnosis to first fill to ongoing therapy is not what most brand teams think it is. The only way to know what it actually looks like is to map it with the people who have walked it. Patient journey mapping done in collaboration with real patients reveals where the drop-off points actually are, which is rarely where the brand assumed. The brands that map the journey honestly and then design pre-fill interventions against the real drop-off points see adherence outcomes that other brands cannot replicate by spending more money on the post-fill side.

A different mental model

The brands moving adherence numbers today are operating from a different mental model than the industry standard. They treat adherence as something that begins forming the first time a patient encounters their condition, and they invest accordingly. They are working on patient trust, comprehension, and activation in the months before a prescription gets written, not in the weeks after one has already been abandoned.

44 million is a number worth sitting with. It is also a number that responds to a different kind of work than the industry has historically done.

If your team is rethinking what adherence work should look like in your therapeutic area, or designing a patient experience for an upcoming launch where the first fill matters as much as the long-term refill, that is a conversation we would welcome.