Medicare AdvantageMay 22, 2023
SPC Exclusions
Measure exclusion criteria: HEDIS® 2023 measurement year
Measure details
Eligibility criteria:
Numerator | Males 21 to 75 years of age and females 40 to 75 years of age who were dispensed at least one high- or moderate-intensity statin medication during 2023. |
Denominator | Males 21 to 75 years of age and females 40 to 75 years of age as of December 31, 2023, who have been diagnosed with clinical atherosclerotic cardiovascular disease (ASCVD) during 2023. |
Did you know?
Many patients listed with a gap for this measure may actually qualify to be excluded from the measure denominator if documented properly.
Measure exclusions:
- Note: Exclusions for advanced illness, frailty, and dispensed dementia medications must come from claims. Other exclusions’ documentation can come from claims data or medical records data. Medical record documentation must include two patient identifiers.
- The advanced illness exclusion can now include telephone visits, e-visits, and virtual check-ins to meet the two visits with an advanced illness diagnosis criteria.
Optional exclusions:
- Death
Mandatory exclusions:
- Dispensed at least one prescription for clomiphene during 2022 or 2023.
- 66 years of age and older who are enrolled in an Institutional Special Needs Plan
(I-SNP) or living long term in an institution during 2023. - 66 years of age and older with advanced illness during 2022 and/or 2023 and frailty during 2023.
- 66 years of age and older with advanced illness during 2022 and/or 2023 and dispensed dementia medication during 2023.
- Diagnosis of pregnancy during 2023.
- Diagnosis of in vitro fertilization in 2022 or 2023.
- Diagnosis of end-stage renal disease (ESRD) or dialysis during 2022 or 2023.
- Diagnosis of cirrhosis during 2022 or 2023
- Diagnosis of myalgia, myositis, myopathy, or rhabdomyolysis during 2023:
- Important note: If patient has a history of myalgia, myositis, myopathy, or rhabdomyolysis in a previous year, this must be documented each year. A diagnosis from a prior year will not carry over to current year.
- Hospice and palliative care.
Closing the gap
Documentation needed:
- Only pharmacy claims are used to identify and close this gap.
- Patient must use their member ID card when filling a statin prescription at the pharmacy.
- Exclusions for advanced illness, frailty and dispensed dementia medications must come from claims. Other exclusions’ documentation can come from claims data or medical records data. Medical record documentation must include two patient identifiers.
Moderate- to high-intensity statin medications on formulary:*
Statin therapy intensity | Generic drug name | Dosage |
Moderate | atorvastatin | 10 mg, 20 mg |
rosuvastatin | 5 mg, 10 mg | |
simvastatin | 20 mg – 40 mg | |
pravastatin | 40 mg, 80 mg | |
lovastatin | 40 mg | |
High | atorvastatin | 40 mg, 80 mg |
rosuvastatin | 20 mg, 40 mg |
*2018 AHA/ACC Guideline on the Management of Blood Cholesterol. J Am Coll Cardiol. 2019 Jun 73 (24) e285-e350)
Best practices
Prescribe low-cost generics to eliminate cost as a barrier:
- Atorvastatin, lovastatin, pravastatin, simvastatin, and rosuvastatin are available for $0 for extended days’ supply prescriptions. These medications are free using the Medicare Advantage prescription drug plan benefit for Anthem Blue Cross and Blue Shield (Anthem) even if the patient reaches the coverage gap.
- Encourage patients to fill their statin medication at a preferred pharmacy using their benefit.
- Discourage the use of discount cards.
- Let Anthem know of any patients filling outside of the benefit. Anthem can reach out to the pharmacy and/or patient regarding the $0 benefit cost.
- Short trial fills of a statin medication with $0 cost may help hesitant patients be more willing to try or re-try a statin medication.
Help patients manage potential side effects:
- Educate patients about the long-term cardiovascular benefits and potential side effects of a statin medication.
- If a patient experienced statin intolerance previously, a trial of a lower dose or of a different statin medication may help reduce risk or side effects.
- Note: If patient has history of statin induced myalgia, myositis, myopathy, or rhabdomyolysis in a previous year, this must be documented each year for patient to be excluded from measure. A diagnosis from a prior year will not carry over to current year.
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
MULTI-BCBS-CR-023040-23-CPN22806
PUBLICATIONS: June 2023 Provider Newsletter
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