Medication Adherence 2025

The Pharmacy Quality Alliance (PQA) is a national quality organization dedicated to improving medication safety, adherence, and appropriate use. These are used to drive improvement efforts surrounding best practices.

HEDIS^® measure

This measure assesses the percentage of plan members 18 years and older with a prescription for a cholesterol medication (a statin drug), a diabetes medication, or a blood pressure medication who fill their prescription often enough to cover 80% or more of the time they are supposed to be taking the medication.

Numerator

Members in the denominator with at least 80% days covered across the classes of cholesterol, diabetes, and/or hypertension medications during the measurement year.

Denominator (eligible patients)

Members at least 18 years old on the last day of the measurement period who have at least two prescriptions filled during the measurement period:

• The first fill date must be between 91 and 365 days before the end of the measurement period.
• Member must have medical eligibility from the first fill to the last day of the measurement period, with no more than one gap of more than 30 days.
• This metric includes members with carveout third party Rx coverage.

Exclusions:

• Patients who use hospice services or elect to use a hospice benefit any time during the measurement year
• End‑stage renal disease or dialysis coverage dates in the measurement year
• Taking Entresto® (hypertension) or insulin (diabetes)
• Inpatient days

Closing the gap

Documentation needed:

• Patient must use their insurance card when filling a statin, diabetes, and/or hypertension prescription at the pharmacy. Using discount cards will not close the gap.
• The proportion of days covered (PDC) is the percent of days in 2024 covered by prescription claims for the same medication or another medication in the therapeutic class, divided by the number of days in the measurement period, multiplied by 100.

Number of days in period covered

PDC (%) = _____________________________________________________ X100

Number of days in period

• PDC is based on the refill history of the patient and considers the days the member has the medication covered and compares that to the total days in the measurement period.
• PDC adjusts for inpatient and skilled nursing facility stays, including the discharge date.

Best practices

Consider extended days’ supply prescriptions:

• Prescribe a 90‑ or 100‑day supply to patients on stable doses of medication.
• Prescribe a one‑year supply of medication at each annual visit to prevent refill gaps.
• If a patient is overdue for follow‑up, send a one‑time, 30‑day refill and immediately contact the patient to schedule an office visit.

Cost or access:

• Prescribe generic mediations from the Anthem $0 copay list when clinically appropriate.
• Offer to send prescriptions to CarelonRx, Inc. Home Delivery:
• E‑prescribe
• Fax to 877-742-4210
• Call 833-203-1742 to phone in prescriptions.
• Identify knowledge gaps, comorbidities, or side effects that may lead to nonadherence.
• Make sure the patient understands the purpose of each medication and the importance of taking it as prescribed.
• Educate on how long side effects may last and offer strategies to overcome them.
• Educate patients about “silent symptoms” and long‑term complications of their diagnoses.
• Screen for depression as a potential contributor to nonadherence.
• Remembering to take medications:
• Engage family members in patient education about medications.
• Suggest pairing medications with a routine activity (for example, brushing teeth), setting alarm/phone reminders, and using OTC benefits to get pill boxes.
• Recommend opt‑in to pharmacy auto‑refill and reminder calls.
• Encourage digital solutions — Our Sydney app can help patients manage their medications.
• Review and simplify medication regimens: consider once‑daily dosing or combination products when appropriate.

Create tools and practices to help patients remain adherent:

• Develop protocols or questionnaires to help understand potential adherence barriers.
• Set your electronic medical record default to a 90‑/100‑day supply.
• When making medication adjustments, issue a new prescription instead of suggesting breaking a tablet in half to ensure prescription directions reflect the new dosage. Discontinue unnecessary medications and consider lower doses.
• Use Real‑Time Prescription Benefit services if applicable through your electronic medical records (EMR).

Let’s work together:

• Regular pharmacy reports indicating current star rating of Medication Adherence measures
• Corporate interventions: gap‑in-care reminders, outbound calls, homebound services, and more

Please visit My Diverse Patients for additional information about eLearning experiences on provider cultural competency and health equity. You can also go to https://www.anthem.com/provider/individual-commercial/medicare-advantage.