Statin Therapy for Patients with Cardiovascular Disease (SPC) 2025

HEDIS^® (Healthcare Effectiveness Data Information Set) is a widely used set of performance measures developed and maintained by NCQA. These are used to drive improvement efforts surrounding best practices.

HEDIS measure

This HEDIS measure looks at the percentage of males 21 to 75 years of age and females 40 to 75 years of age during the measurement year, who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria.

Numerator

Male patients 21 to 75 years old and females 40 to 75 years old with ASCVD who were dispensed at least one high‑ or moderate‑intensity statin with any day supply during the measurement year

Denominator

Male patients 21 to 75 years old and females 40 to 75 years old with ASCVD

Exclusions:

• Patients who use hospice services or elect to use a hospice benefit any time during the measurement year
• Patients who die any time during the measurement year
• Patients with a diagnosis of pregnancy during the measurement year or the year prior to the measurement year. Do not include laboratory claims (claims with POS code 81).
• In vitro fertilization in the measurement year or the year prior to the measurement year
• Dispensed at least one prescription for clomiphene during the measurement year or the year prior to the measurement year
• End stage renal disease (ESRD) during the measurement year or the year prior to the measurement year. Do not include laboratory claims (claims with POS code 81).
• Dialysis during the measurement year or the year prior to the measurement year
• Cirrhosis during the measurement year or the year prior to the measurement year. Do not include laboratory claims (claims with POS code 81).
• Myalgia, myositis, myopathy, or rhabdomyolysis during the measurement year. Do not include laboratory claims (claims with POS code 81)
• Myalgia or rhabdomyolysis caused by a statin any time during the member’s history through December 31 of the measurement year
• Patients receiving palliative care any time during the measurement year
• Patients who had an encounter for palliative anytime during the measurement year. Do not include laboratory claims (claims with POS code 81).
• Patients 66 years of age and older as of December 31 of the measurement year (all product lines) with frailty and advanced illness. Patients must meet both frailty and advanced illness criteria to be excluded. Do not include laboratory claims (claims with POS code 81).
• Medicare patients 66 years of age and older as of December 31 of the measurement year who meet either of the following:
• Enrolled in an institutional special needs plan (I‑SNP) any time during the measurement year
• Living long‑term in an institution any time during the measurement year

Eligibility

Documentation needed:

• Event: Patients with one of the following during the year prior to measurement year:
• Discharged from an inpatient setting with myocardial infarction on the discharge claim
• Coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), or other revascularization in any setting
• Diagnosis: patients with one encounter with a diagnosis of ischemic vascular disease (IVD) during both the measurement year and year prior:
• An outpatient visit, telephone visit, e‑visit, virtual check‑in, or acute inpatient encounter with an IVD diagnosis
• At least one acute inpatient discharge with an IVD diagnosis

High‑ and moderate‑intensity statin medications

High intensity statins:

• Amlodipine‑atorvastatin 40 to 80 mg
• Atorvastatin 40 to 80 mg
• Ezetimibe‑simvastatin 80 mg
• Rosuvastatin 20 to 40 mg
• Simvastatin 80 mg

Moderate intensity statins:

• Atorvastatin 10 to 20 mg
• Amlodipine‑atorvastatin 10 to 20 mg
• Rosuvastatin 5 to 10 mg
• Simvastatin 20 to 40 mg
• Ezetimibe‑simvastatin 20 to 40 mg
• Pravastatin 40 to 80 mg
• Lovastatin 40 mg
• Fluvastatin 40 to 80 mg
• Pitavastatin 1 to 4 mg

Best practices:

• Educate patients on the importance of taking the medication.
• Prescribe medications on the low or no‑cost medication list.
• Educate patients to use their Anthem pharmacy benefits, as applicable.
• Encourage members to use mail order pharmacy benefits through CarelonRx, Inc.
• Encourage the use of extended day supply.
• Make sure the dose is a moderate or high intensity medication and not a low dose intensity medication.
• Assess for measures exclusions every year and document or code for the exclusion. Note some exclusions are prior year or current year.

Let’s work together

Measure is closed via:

• Supplemental data
• Claims
• Cotiviti (Exclusions or proof of prescription filled without using Anthem benefits. Medical record/pharmacy label are acceptable if they contain all the required components (name of drug, strength/dose, route, date when medication was dispensed. Need label of the medication that was dispensed, date, and name.)

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