Product Lines:
Advantage MD, EHP, Priority Partners, and USFHP.

Measurement Period: January 1–December 31.

Description:
Percentage of persons ages 40–75 during the measurement period with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following criteria for the two rates.

1. Received Statin Therapy. Persons who were dispensed at least one statin medication of any intensity during the measurement period.
2. Statin Adherence 80%. Persons who remained on a statin medication of any intensity for at least 80% of the treatment period

Measure Reporting:
HealthChoice Performance Measure reporting for Priority Partners.

Improvement Notation:
Increased score indicates improvement.

Data Collection: 

• ECDS

Initial Population:

• Measure Item Count: Person.
• Age: 40-75 years of age as of the last day of the measurement period.
• Benefits: Medical. Pharmacy during the measurement period.
• Continuous Enrollment: The measurement period and the year prior to the measurement period.
• Allowable Gap: No more than one gap of ≤45 days during each year of continuous enrollment. No gaps on the last day of the measurement period.

Definition:
IPSD- Index prescription start date: The earliest prescription dispensing date for any statin medication of at least moderate intensity during the measurement period.

PDC- Proportion of days covered: The number of days the person is covered by at least one statin medication prescription of appropriate intensity, divided by the number of days in the treatment period.

Treatment period: The period of time beginning on the IPSD through the last day of the measurement period.

Denominator:
Denominator 1: Received statin therapy.
Persons who meet specified age and clinical criteria—based on qualifying diabetes diagnoses and diabetes medication list—and do not meet any denominator exclusion criteria and received statin therapy.

Persons with a diagnosis of diabetes.
Either of the following meets criteria:

• Claim/encounter data. At least two diagnoses of diabetes on different dates of service during the measurement period or the year prior to the measurement period.
• Pharmacy data. At least one diagnosis of diabetes and at least one diabetes medication dispensing event of insulin or a hypoglycemic/antihyperglycemic medication during the measurement period or the year prior to the measurement period.

Denominator 2: Statin adherence 80%.
Persons who meet numerator 1 criteria.

Note: All persons who are numerator compliant for Rate 1 must be used as the denominator for Rate 2.

Numerator:
Numerator 1 - Received statin therapy.
At least one dispensing event for a high-intensity or moderate-intensity or low-intensity statin medication during the measurement period.

Numerator 2 - Statin adherence 80%.
PDC of at least 80% during the treatment period.

Summary of changes:

• This is the first year the measure is reported using ECDS.
• Removed the Administrative Data Collection Method.
• Removed the requirement to use the same data source for rate 1 and rate 2.
• Updated the ASCVD diagnosis criteria in the denominator exclusions to allow diagnoses to occur in the measurement period or the year prior to the measurement period.
• Removed denominator exclusion for persons enrolled in an I-SNP or living long-term in an institution.
• Updated the denominator exclusion to remove persons with an ASCVD diagnosis.

Best Practice and Measure Tips

• Educate patients with diabetes that their condition places them at increased risk for atherosclerotic cardiovascular disease, including heart disease and stroke, and that statin therapy can help reduce this risk.
• Adherence for the SPD measure is determined by the member remaining on their prescribed high or low intensity statin medication for 80% of their treatment period.
• Adherence is determined by pharmacy claims data (the plan will capture data each time the member fills their prescription).
  • Gap closure depends on pharmacy claims.
  • Evaluate the appropriateness of prescribing a 90-day supply to optimize medication adherence and reduce refill frequency.
  • Consider including prescribing directives that instruct the dispensing pharmacy to adjudicate the claim through the patient’s pharmacy benefit plan. The use of discount programs, paying cash for medication and medication samples will not count toward gap closure.
• Experiencing adverse effects:
  • Instruct patients to contact their practitioner if they are experiencing adverse effects.
  • Document any adverse effects from statin therapy.
  • Determine if the signs/symptoms qualify as an exclusion.
  • Try reducing the dose or frequency or consider trying a different statin medication.
• Mail Order Pharmacy Program
  •  Advantage MD Mail Order Best Practices
    • One of the most important ways to improve the health of our members is to make sure they receive and take their medications as you prescribe. Our mail order pharmacy, CVS Caremark, can help. CVS Caremark sends a three month supply of maintenance medications in one fill, making it easier for the patient only having to fill four times a year. In addition, a three month supply of maintenance medication on Tier 1 through 4 is available through CVS Caremark mail order at a reduced copay. This means your patient can fill a 100-day supply of Tier 1 medication and a 90-day supply of Tier 2 through 4 medication for only 2 times the retail copay—saving them an equivalent of four retail copays per year. Talk to your patients today about mail order pharmacy with CVS Caremark for better health and health care spending. Doctors and staff can contact CVS Caremark by calling the number below, 24 hours a day, seven days a week.
      • PPO members: 877-293-5325
      • HMO members: 877-293-4998
  • EHP CVS Caremark® Mail Service Pharmacy (mail order prescriptions): 
    
    • This service offers a convenient and cost-effective option for obtaining medications on an ongoing basis. Member receive up to a 90 day supply of chronic use medications, delivered to their door.
    • Provider can send an electronic prescription to CVS Caremark® Mail Service Pharmacy. This is the easiest way to get started – Member can expect to get their medication in 7 to 10 business days.
    • For more information visit CVS Caremark.
  • US Family Health Plan
    • Home delivery is available to USFHP members for up to a 90-day supply of approved medications through Walgreens pharmacy. Home delivery is best suited for medications you take on a regular basis. 
    • Members who live in Maryland: 
      
      • To obtain prescription through home delivery complete the Maryland mail order form and send it in with your valid prescription. 
      • Refills: recommend members to reorder at least two weeks before supply runs out to ensure members receive their refill on time.
        • Walgreens Pharmacy
          2700 Remington Ave.
          Baltimore, MD 21211
          Phone: 410-235-2128
          Fax: 410-889-1609
    • Members who live outside of Maryland:
      • To obtain prescription through home delivery from Walgreens Mail Service fill out the home delivery registration and prescription order form and mail to:
        
        • Walgreens Mail Service
          P.O. Box 29061
          Phoenix, AZ 85038-9601
          Phone: 800-345-1985 TTY: 800-925-0178
          En Español: 800-778-5427 TTY: 877-220-6173
          Hours of operation: 24 hours a day, 7 days a week
      • For more information, visit the Walgreens Mail Service website or view their brochure.

Measure Exclusions

Denominator Exclusions:

• Persons receiving palliative care or who had an encounter for palliative care any time during the measurement period.
• Persons  in hospice or using hospice services any time during the measurement period.
• Members who died any time during the measurement period.
• Persons 66 years of age or older by the last day of the measurement period, with both frailty and advanced illness.
• Persons who received in vitro fertilization, had a diagnosis of pregnancy, or were dispensed at least one prescription for during the measurement period or the year prior to the measurement period. 
• Persons with a diagnosis of ESRD or cirrhosis , or who received dialysis during the measurement period or the year prior to the measurement period.
• Persons with myalgia, myositis, myopathy or rhabdomyolysis during the measurement period. 
• Persons with myalgia or rhabdomyolysis caused by a statin any time during the person’s history through December 31 of the measurement period.
• MI, CABG, PCI or other revascularization during the year prior to the measurement period.
• ASCVD during the measurement period or the year prior to the measurement period.
  
   

Exclusion Codes

Muscular Pain and Disease

• Myopathy ICD-10-CM: G72.0, G72.2, G72.9
• Myositis ICD-10-CM: M60.80, M60.811, M60.812, M60.819, M60.821, M60.822, M60.829, M60.831, M60.832, M60.839, M60.841, M60.842, M60.849, M60.851, M60.852, M60.859, M60.861, M60.862, M60.869, M60.871, M60.872, M60.879, M60.88, M60.89, M60.9
• Rhabdomyolysis ICD-10-CM: M62.82
• Myalgia ICD-10-CM: M79.10, M79.11, M79.12, M79.18
• SNOMED CT US Edition: 726531007, 1264013004, 1264014005, 1264016007, 1264024002, 1264027009, 1264028004, 1264030002, 1264031003, 1264034006, 1264035007, 1296686009, 28221000119103, 41321000119101, 113611000119100, 610921000124106*

Muscular Reactions to Statins SNOMED CT US Edition: 

• 787206005-Rhabdomyolysis due to statin (disorder)
• 16462851000119106- Myalgia caused by statin (finding)
• 16524291000119105- History of myalgia caused by statin (situation)
• 16524331000119104- History of rhabdomyolysis due to statin (situation)

Cirrhosis

• ICD-10-CM: K70.30, K70.31, K71.7, K74.3, K74.4, K74.5, K74.60, K74.69, P78.81
• SNOMED CT US Edition: 536002, 1761006, 6183001, 12368000, 15999000, 16070004, 19943007, 21861000, 27156006, 31712002, 33144001, 37688005, 43904005, 74669004, 76301009, 78208005, 86454000, 89580002, 109819003, 123604002, 123605001, 123606000, 123716002, 123717006, 128072003, 197291001, 197293003, 197294009, 197296006, 197299004, 197300007, 197301006, 197303009, 197305002, 197310003, 235895002, 235896001, 235897005, 266468003, 266469006, 266470007, 266471006, 271440004, 371139006, 419728003, 420054005, 425413006, 699189004, 702377007, 715401008, 715864007, 716203000, 725416005, 725938001, 725939009, 725940006, 735733008, 871619002, 897004000, 897005004,1010616001, 831000119103, 103611000119102, 1082601000119104

ESRD Diagnosis 

• ICD-10-CM: N18.5, N18.6
• SNOMED CT US Edition: 46177005, 236434000, 236435004, 236436003, 433146000, 698810000, 704667004, 707324008, 712487000, 714152005, 714153000, 1332467008, 711000119100, 90761000119106, 90771000119100, 90791000119104, 96711000119105, 111411000119103, 120261000119101, 127991000119101, 128001000119105, 129161000119100, 140101000119109, 153851000119106, 153891000119101, 285011000119108, 285841000119104, 286371000119107, 368461000119103, 368471000119109, 434431000124103

Dialysis Procedure

•  CPT: 90935, 90937, 90945, 90947, 90997, 90999, 99512
• HCPCS: G0257, S9339
• ICD10PCS: 3E1M39Z, 5A1D00Z, 5A1D60Z, 5A1D70Z, 5A1D80Z, 5A1D90Z
• SNOMED CT US Edition: 676002, 11932001, 14684005, 34897002, 57274006, 67970008, 68341005, 71192002, 108241001, 225230008, 225231007, 233575001, 233576000, 233577009, 233578004, 233579007, 233580005, 233581009, 233582002, 233583007, 233584001, 233585000, 233586004, 233587008, 233588003, 233589006, 233590002, 238318009, 238319001, 238321006, 238322004, 238323009, 265764009, 288182009, 302497006, 427053002, 428648006, 698074000, 708930002, 708931003, 708932005, 708933000, 708934006, 714749008, 715743002, 895382009, 1231768001

IVF 

• HCPCS: S4015, S4016, S4018, S4020, S4021
• SNOMED CT US Edition: 52637005, 225248004, 425866000, 425901007, 426417003, 426914002, 427664000, 711544002, 10231000132102

Pregnancy 

• ICD-10-CM Maternal conditions: O00-O9A*
• ICD-10-CM Encounter: Z03.71, Z03.72, Z03.73, Z03.74, Z03.75, Z03.79, Z33.1, Z33.2, Z33.3, Z34.00, Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82, Z34.83, Z34.90, Z34.91, Z34.92, Z34.93, Z36.0, Z36.1, Z36.2, Z36.3, Z36.4, Z36.5, Z36.81, Z36.82, Z36.83, Z36.84, Z36.85, Z36.86, Z36.87, Z36.88, Z36.89, Z36.8A, Z36.9 
• SNOMED CT US: 199305006, 199050003, 10750801000119102, 703309000, 300571009, 366323009, 428567001, 428930004, 429715006, 313180007, 428566005, 313178001, 428058009, 433601000124106, 441924001, 417570003, 11687002, 75022004, 46894009, 40801000119106, 10753491000119101, 237285000, 199141002, 77376005, 34165000, 724485008, 300573007, 300572002, 416402001, 609516006, 609519004, 86081009, 27152008, 87621000, 33370009, 1142097006, 80224003, 1142048002, 10751701000119102, 472699005*

Atherosclerotic Cardiovascular Disease 

• ICD-10-CM: I20.0, I20.1, I20.2, I20.81, I20.89, I20.9, I24.0, I24.81, I24.89, I24.9, I25.110, I25.5, I25.6, I25.700, I25.810, I25.812, I25.82, I25.9, I63.20, I63.50, I65.01, I66.01, I70.211, I75.011, T82.855A, T82.856A*

MI

• ICD-10-CM: I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4, I21.A9, I21.B, I22.0, I22.1, I22.2, I22.8, I22.9, I23.0, I23.1, I23.2, I23.3, I23.4, I23.5, I23.6, I23.7, I23.8, I25.6
• SNOMED CT US Edition*

Old Myocardial Infarction

• ICD-10-CM: I25.2
• SNOMED CT US Edition: 1755008, 32574007, 233839009, 233840006, 233841005, 233842003, 35401000087106, 35411000087108, 35421000087100, 35431000087103, 35441000087109, 35451000087107

CABG

• CPT: 33510, 33511, 33512, 33513, 33514, 33516, 33517, 33518, 33519, 33521, 33522, 33523, 33530, 33533, 33534, 33535, 33536
• HCPCS: S2205, S2206, S2207, S2208, S2209
• ICD-10-PCS: 0210083, 0210088, 0210089, 0210093, 0210098, 0210099, 0211083, 0211088, 0211089, 0211093, 0211098, 0211099, 0212083, 0212088, 0212089, 0212093, 0212098, 0212099, 0213083, 0213088, 0213089, 0213093, 0213098, 0213099, 021008C, 021008F, 021008W, 021009C, 021009F, 021009W, 02100A3, 02100A8, 02100A9, 02100AC, 02100AF, 02100AW, 02100J3, 02100J8, 02100J9, 02100JC, 02100JF, 02100JW, 02100K3, 02100K8, 02100K9, 02100KC, 02100KF, 02100KW, 02100Z3, 02100Z8, 02100Z9, 02100ZC, 02100ZF, 021108C, 021108F, 021108W, 021109C, 021109F, 021109W, 02110A3, 02110A8, 02110A9, 02110AC, 02110AF, 02110AW, 02110J3, 02110J8, 02110J9, 02110JC, 02110JF, 02110JW, 02110K3, 02110K8, 02110K9, 02110KC, 02110KF, 02110KW, 02110Z3, 02110Z8, 02110Z9, 02110ZC, 02110ZF, 021208C, 021208F, 021208W, 021209C, 021209F*
• SNOMED CT US Edition: 3546002, 8876004, 10190003, 10326007, 14323007, 17073005, 29819009, 30670000, 39202005, 39724006, 48431000, 61236006, 67166004, 74371005, 82247006, 90487008, 119564002, 119565001, 175021005, 175029007, 175047001, 175048006, 175050003*

PCI

• CPT: 92920, 92924, 92928, 92930, 92933, 92937, 92941, 92943, 92945
• HCPCS: C9600, C9602, C9604, C9606, C9607
• ICD-10-PCS: 0270346, 0270356, 0270366, 0270376, 0270446, 0270456, 0270466, 0270476, 0271346, 0271356, 0271366, 0271376, 0271446, 0271456, 0271466, 0271476, 0272346, 0272356, 0272366, 0272376, 0272446, 0272456, 0272466, 0272476, 0273346, 0273356, 0273366, 0273376, 0273446, 0273456, 0273466, 0273476, 02703E6, 02704E6, 02713E6, 02714E6, 02723E6, 02724E6, 02733E6, 02734E6, 027034Z, 027035Z, 027036Z, 027037Z, 02703D6, 02703DZ, 02703EZ, 02703F6, 02703FZ, 02703G6, 02703GZ, 02703T6, 02703TZ, 02703Z6, 02703ZZ, 027044Z, 027045Z, 027046Z, 027047Z, 02704D6, 02704DZ, 02704EZ, 02704F6, 02704FZ, 02704G6, 02704GZ, 02704T6, 02704TZ, 02704Z6, 02704ZZ, 027134Z, 027135Z, 027136Z, 027137Z, 02713D6, 02713DZ, 02713EZ, 02713F6, 02713FZ, 02713G6, 02713GZ, 02713T6, 02713TZ, 02713Z6, 02713ZZ, 027144Z, 027145Z, 027146Z, 027147Z, 02714D6, 02714DZ, 02714EZ, 02714F6, 02714FZ, 02714G6, 02714GZ, 02714T6, 02714TZ, 02714Z6, 02714ZZ, 027234Z, 027235Z, 027236Z, 027237Z, 02723D6, 02723DZ, 02723EZ, 02723F6, 02723FZ, 02723G6, 02723GZ, 02723T6, 02723TZ, 02723Z6, 02723ZZ, 027244Z, 027245Z, 027246Z, 027247Z, 02724D6, 02724DZ, 02724EZ, 02724F6, 02724FZ, 02724G6, 02724GZ, 02724T6, 02724TZ, 02724Z6, 02724ZZ, 027334Z, 027335Z, 027336Z, 027337Z, 02733D6, 02733DZ, 02733EZ, 02733F6, 02733FZ, 02733G6, 02733GZ, 02733T6, 02733TZ, 02733Z6, 02733ZZ, 027344Z, 027345Z, 027346Z, 027347Z, 02734D6, 02734DZ, 02734EZ, 02734F6, 02734FZ, 02734G6, 02734GZ, 02734T6, 02734TZ, 02734Z6, 02734ZZ
• SNOMED CT US Edition: 11101003, 36969009, 68466008, 75761004, 80762004, 85053006, 91338001, 175066001, 232726007, 232727003, 232728008, 232729000, 232731009, 397193006, 397431004, 414089002, 415070008, 428488008, 429499003, 429639007, 429809004, 609153008, 609154002, 707828002, 713617008, 763725002, 868245005, 868246006, 868247002, 868248007, 1217277007, 1217309008, 1222571004, 1222673007, 1222674001, 1258930006, 1258931005

Other Revascularization

• CPT: 37220, 37221, 37224, 37225, 37226, 37227, 37228, 37229, 37230, 37231, 37254, 37256, 37258, 37260, 37263, 37265, 37267, 37269, 37271, 37273, 37275, 37277, 37280, 37282, 37284, 37286, 37288, 37290, 37292, 37294, 37296, 37298
• SNOMED CT US Edition: 233497001, 233498006, 233499003, 233500007, 233505002, 233506001

*Please note that not all codes are listed here. For access to the complete set of codes, contact your Provider Engagement Liaison or email [email protected].

Measure Medications

To comply with this measure, one of the following medications must have been dispensed:

•  Amlodipine Atorvastatin 
• Atorvastatin 
• Ezetimibe Simvastatin 
• Rosuvastatin 
• Simvastatin 

Moderate-intensity statin therapy

•  Amlodipine Atorvastatin 
• Atorvastatin 
• Ezetimibe Simvastatin 
• Fluvastatin 
• Lovastatin 
• Pitavastatin 
• Pravastatin 
• Rosuvastatin Simvastatin 

Low-intensity statin therapy

• Ezetimibe Simvastatin 
• Fluvastatin 
• Lovastatin 
• Pravastatin 
• Simvastatin 

Alpha-glucosidase inhibitors

• Acarbose
• Miglitol

• Pramlintide

• Alogliptin-metformin 
• Alogliptin-pioglitazone
• Canagliflozin-metformin
• Dapagliflozin-metformin
• Dapagliflozin-saxagliptin
• Empagliflozin-linagliptin
• Empagliflozin-metformin
• Empagliflozin-linagliptin-metformin
• Ertugliflozin-metformin
• Ertugliflozin-sitagliptin
• Glimepiride-pioglitazone
• Glipizide-metformin
• Glyburide-metformin
• Linagliptin-metformin 
• Metformin-pioglitazone
• Metformin-rosiglitazone
• Metformin-saxagliptin
• Metformin-sitagliptin

• Insulin aspart 
• Insulin aspart-insulin aspart protamine
• Insulin degludec 
• Insulin degludec-liraglutide
• Insulin detemir
• Insulin glargine
• Insulin glargine-lixisenatide 
• Insulin glulisine 
• Insulin isophane human
• Insulin isophane-insulin regular
• Insulin lispro
• Insulin lispro-insulin lispro protamine 
• Insulin regular human

• Nateglinide
• Repaglinide

• Metformin

•  Albiglutide
• Dulaglutide
• Exenatide
• Liraglutide
• Lixisenatide 
• Semaglutide
• Tirzepatide

• Canagliflozin
• Dapagliflozin
• Empagliflozin
• Ertugliflozin

• Chlorpropamide
• Glimepiride
• Glipizide
• Glyburide
• Tolazamide
• Tolbutamide

•  Pioglitazone
• Rosiglitazone

• Alogliptin
• Linagliptin
• Saxagliptin
• Sitagliptin