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Objective: This study was undertaken to characterize trajectories of antiseizure medication (ASM) adherence in adults with newly treated epilepsy and to determine predictors of trajectories. Methods: This was a retrospective cohort study using Medicare. We included beneficiaries with newly treated epilepsy (one or more ASM and none in the preceding 2 years, plus International Classification of Diseases codes) in 2010–2013. We calculated the proportion of days covered (proportion of total days with any ASM pill supply) for 8 quarters or until death. Group‐based trajectory models characterized and determined predictors of trajectories. Results: We included 24 923 beneficiaries. Models identified four groups: early adherent (60%), early nonadherent (18%), late adherent (11%), and late nonadherent (11%). Numerous predictors were associated with being in the early nonadherent versus early adherent group: non‐White race (e.g., Black, odds ratio [OR] = 1.7, 95% confidence interval [CI] = 1.5–1.8), region (e.g., South vs. Northeast: OR = 1.2, 95% CI = 1.1–1.4), and once daily initial medication (OR = 1.1, 95% CI = 1.0–1.3). Predictors associated with decreased odds of being in the early nonadherent group included older age (OR =.9 per decade, 95% CI =.9–.9), female sex (OR =.9, 95% CI =.8–1.0), full Medicaid eligibility (OR =.6, 95% CI =.4–.8), neurologist visit (OR =.6, 95% CI =.6–.7), and initial older generation ASM (OR =.6, 95% CI =.6–.7). Significance: We identified four ASM adherence trajectories in individuals with newly treated epilepsy. Whereas risk factors for early nonadherence such as race or geographic region are nonmodifiable, our work highlighted a modifiable risk factor for early nonadherence: lacking a neurologist. These data may guide future interventions aimed at improving ASM adherence, in terms of both timing and target populations. [ABSTRACT FROM AUTHOR]