Adherence to medication under mandatory and voluntary mail benefit designs

Am J Manag Care. 2011 Jul 1;17(7):e260-9.


Objective: To compare adherence rates under voluntary and mandatory mail benefit designs.

Study design: Matched retrospective cohort.

Methods: Adherence rates in the first year of therapy were compared between voluntary and mandatory mail cohorts composed of individuals who initiated statin, angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker (ARB), platelet aggregation inhibitor, metformin, glitazone, or sulfonylurea therapy at a retail pharmacy between January 1 and March 31, 2009. Initiators in mandatory mail plans were matched on therapeutic class, age, sex, prospective risk, and cost of initial prescription with those in voluntary mail plans. Logistic regression models of optimal adherence were constructed to adjust for measured confounders.

Results: Persistence rates were similar through the first 60 days of therapy. The mandatory mail cohort had a notable drop in persistence by day 90 (63.3% vs 56.3%, P <.001), with a more pronounced drop among those without previous mail-service pharmacy use (50.5%). Median medication possession ratio (49.2% vs 57.4%) and optimal adherence (33.6% vs 36.1) were also lower. In the multivariable models, mandatory mail participants were less likely to achieve optimal adherence overall (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.67-0.74) and in the metformin (OR 0.55), sulfonylurea (OR 0.72), ACE inhibitor (OR 0.74), ARB (OR 0.69), and statin (OR 0.69) classes. Participants with no prior use of mail-service pharmacy had significantly lower odds of achieving optimal adherence in all therapeutic classes.

Conclusions: Mandatory mail appears to cause some members to discontinue therapy prematurely, particularly those without previous mail service pharmacy experience.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Age Factors
  • Aged
  • Angiotensin Receptor Antagonists / therapeutic use
  • Angiotensin-Converting Enzyme Inhibitors / therapeutic use
  • Cohort Studies
  • Female
  • Humans
  • Male
  • Medication Adherence / statistics & numerical data*
  • Metformin / therapeutic use
  • Middle Aged
  • Pharmaceutical Services / statistics & numerical data*
  • Platelet Aggregation Inhibitors / therapeutic use
  • Postal Service / statistics & numerical data*
  • Prescription Drugs / economics*
  • Prescription Fees
  • Sex Factors
  • Sulfonylurea Compounds / therapeutic use
  • Thiazolidinediones / therapeutic use


  • Angiotensin Receptor Antagonists
  • Angiotensin-Converting Enzyme Inhibitors
  • Platelet Aggregation Inhibitors
  • Prescription Drugs
  • Sulfonylurea Compounds
  • Thiazolidinediones
  • Metformin