Statin Use in Persons with Cardiovascular Disease (SPC) measure exclusion criteria: HEDIS^® 2024 measurement year

Measure details

Eligibility criteria:

Did you know?

Certain adverse reactions to a statin medication may exclude the patient from the measure denominator if properly documented. See required exclusions below.

Required exclusions:

• Diagnosis of myalgia, myositis, myopathy, or rhabdomyolysis during 2024:
  • Important note: The above exclusionary diagnoses must be documented each year. A diagnosis from a prior year will not carry over to the current year.  These exclusionary diagnoses can come from claims or medical record data.  Medical record documentation must contain two patient identifiers.
• Diagnosis of pregnancy during 2024
• Diagnosis of in-vitro fertilization in 2023 or 2024
• Dispensed at least one prescription for clomiphene during 2023 or 2024
• 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 2024
• 66 years of age and older with advanced illness during 2023 and/or 2024 and frailty during 2024
• 66 years of age and older with advanced illness during 2023 and/or 2024 and dispensed dementia medication during 2024:
  • Note: Exclusions for advanced illness, frailty, and dispensed dementia medications must come from claims.
  • The advanced illness exclusion can include telephone visits, e-visits, and virtual check-ins to meet the two visits with an advanced illness diagnosis criterion.
• Diagnosis of end-stage renal disease (ESRD) or dialysis during 2023 or 2024
• Diagnosis of cirrhosis during 2023 or 2024
• Hospice and palliative care
  • Death

Closing the gap

Documentation needed:

• Only dispensed medication on a pharmacy claim is 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.
• Exclusions for myalgia, myositis, myopathy, or rhabdomyolysis can come from claims or medical record data. Medical record documentation must include two patient identifiers.

Moderate- to high-intensity statin medications

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 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 different statin medication may help reduce risk or side effects.

Note: Patient history of statin-induced myalgia, myositis, myopathy, or rhabdomyolysis in a prior year must be documented each year for patient to be excluded from this measure. A diagnosis from a prior year will not carry over to the current year.