Medication data reveals a new member’s health risk—before the first claim

To provide the most effective care, health plans need timely and accurate insight into a new member’s health, including the chronic conditions they’re already managing.

While health plans traditionally rely on clinical and claims data to understand a member’s health, that information isn’t available for new members and claims typically don’t arrive until 30 to 90 days after the date of service. That blind spot falls squarely within the first 90 days of enrollment—the same window that sets a new member’s cost, utilization and outcomes trajectory, and where value-based care and complex-care management programs have the most leverage to intervene.

Medication data offers health plans an earlier and actionable signal. By analyzing dispensed medication and pharmacy benefit data, health plans can see—in near real time—what conditions and disease states are actively being treated.

To explore how prescription history can be used to quickly identify disease burden—well before the first claim—Surescripts conducted a retrospective, observational analysis of de-identified medication dispensing and pharmacy benefit manager (PBM) data. We examined a random sample of 20,000 U.S. adults ages 35–65 whose clinician requested medication history between December 1–10, 2025.

Among this treatment-active sample, nearly 70% of members were being treated for at least one of four common chronic conditions: hypertension, hyperlipidemia, diabetes or asthma/COPD.

These conditions drive long-term cost and clinical risk—and medication data surfaced them quickly and early, without waiting for a claim.

Nearly 80% of members were being treated for one of the additional common conditions examined: depression/anxiety, osteoarthritis/pain, dermatology conditions or GERD/stomach issues.

Medication data helps plans see who they’re managing from a whole-person perspective—from the start of enrollment, rather than weeks later as claims accumulate, and benefits are used.

More than half of the cohort were being treated for both a chronic condition and an additional condition at the same time.

These are members a health plan wants to engage early, as their care will likely involve more than one health challenge to work through to make a meaningful impact.

More than a third of the cohort were being treated for two or more chronic conditions, and nearly half for two or more additional conditions.

One chronic condition is rarely the whole story. This is a population with a high, layered disease burden—a strong directional signal of emerging risk and complexity that health plans often can’t see until well into the plan year, if at all.

Across the sample examined, members were taking medication for the following conditions:

Hypertension—47.4%
Depression/anxiety—45.6%
Osteoarthritis/pain—39.9%
Hyperlipidemia—32.7%
Dermatology—29.0%
GERD/stomach issues—28.1%
Asthma/COPD—27.4%
Diabetes—20.6%

These conditions span cardiovascular, metabolic, respiratory and behavioral and physical health needs and underscore how much of a member’s risk profile is visible in medication data alone.

Early visibility matters. Health plans already have medication adherence, care management and outreach programs in place. The hard part is knowing which new members need that support—and knowing it as soon as possible, not a quarter into the plan year.

Medication data gives health plans a strong, directional read on emerging risk and complexity. While it’s important to note that this data is a directional signal of potential disease burden; it does not constitute a clinical diagnosis. Medications may be prescribed for multiple conditions. With that in mind, medication data can help health plans identify and engage high-risk members sooner and pursue opportunities to improve health outcomes and manage cost trajectories over time.

Surescripts Medication History for Populations draws medication dispensing and PBM data from a broad network of pharmacies and PBMs, giving health plans and the technology vendors that serve them a view of a new member's treated disease burden for a member population within one or two days of the request. And because that data is actionable—at the member level, plans can identify members who may need support, stratify risk and begin engagement before the first claim arrives.