Reaching who actually needs you: a guide to health claims-based targeting

The most sophisticated B2B2C health marketers are moving beyond “blast the whole eligible population” and basic demographic targeting toward using medical claims and pharmacy data to identify who is most likely to need — and convert on — a specific benefit. Here's how claims-based targeting works, what results to expect, and how to make the case internally.

The Problem With Blanket Campaigns

Here's the uncomfortable truth about most enrollment campaigns: you're spending a meaningful chunk of your budget telling people about benefits they don't need. An MSK solution sent to a population where 80% have no musculoskeletal issues isn't just inefficient — it erodes trust in the benefit itself. Broad campaigns benchmark around 1% enrollment, not because the product or marketing is bad, but because most of the audience simply isn't the right audience at that moment.

What Claims-Based Marketing Actually Is

Claims-based marketing uses medical and pharmacy claims data — typically sourced from the health plan, PBM, or a data intermediary — to identify members showing patterns consistent with the conditions your product addresses. Claims data is one of the most reliable proxies for current health need. As one digital health company described it: “We have a machine learning algorithm that feeds into our CRM to send targeted, timely campaigns to those identified as likely to need the procedures or care we offer.” Raw claims tell you what happened; predictive modeling tells you what's likely next.

Pharmacy data is especially actionable for behavioral health, chronic conditions, and categories where prescription patterns signal need. One marketer noted: “We received prescription data from PBMs that we used to retarget folks likely to suffer from insomnia or anxiety.” And for program-replacement scenarios — reaching members already in a relevant treatment regimen — the data advantage compounds, because continuity of care is itself a conversion driver.

Benchmarks: What Narrowing the Funnel Delivers

The lift is real and measurable, though the numbers vary by targeting type, category, and mechanics. On the broad-to-targeted shift: “Enrollment benchmarks of ~1% with broad campaigns and ~1–3% with targeted campaigns.” That may sound modest, but if your audience drops from 50,000 to 5,000 while your conversion triples, your cost per enrollment improves dramatically.

For multi-touch campaigns over several months, one practitioner sees 5–15% of the target audience converting over the course of a program. For Rx-based targeting and 1:1 vendor swaps, engagement runs ~50–75%, because continuity of care is such a strong driver. And channel matters: for Medicare and high-cost-claimant populations, proactive phone outreach consistently outperforms — the channel has to match the audience, not just the data.

Compliance You Cannot Skip

Claims-based targeting operates in highly regulated territory. HIPAA governs the use of protected health information, and the rules around marketing use are nuanced. You almost certainly need legal and compliance in the room before building any workflow. A few principles practitioners converge on: use data at the cohort level rather than the individual level where possible; govern PBM and health-plan data sharing with appropriate business associate agreements; take extra care with behavioral health and substance-use claims (which carry additional protections under 42 CFR Part 2); and document your data lineage. The compliance burden is real — but it's a reason to build the right infrastructure, not to avoid the strategy.

Making the Internal Case

The ROI case is compelling on paper, but buy-in for data licensing, compliance infrastructure, and ML capabilities is a real challenge. Start with a pilot on a single condition where the claims signal is cleanest and broad-campaign performance is weakest — a clean before-and-after on cost per enrollment is the most persuasive document you can bring. Connect the investment to the client renewal story: higher utilization among high-need members is a health-outcomes story, which lands differently with benefits buyers. And frame the denominator correctly: a 10% conversion on 2,000 targeted members is a stronger result than 1% on 50,000 blasted ones, even when the absolute counts look similar.

Key Takeaways

Broad campaigns benchmark around 1%; claims-based targeting reaches 3–5% on digital and 5–15% on multi-touch programs. Program-replacement and continuity-of-care scenarios are the highest performers, at 50–75% engagement. PBM pharmacy data is among the most actionable sources. Compliance infrastructure is non-negotiable. Match the channel to the population. And make the internal case on cost per enrollment and health outcomes — not absolute volume.