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

Eligible Population:
Members ages 40–75 during the measurement year. This includes HealthChoice Performance Measure reporting for Priority Partners. 

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

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

Continuous Enrollment:

• The measurement year and the year prior to the measurement year.

Best Practice and Measure Tips

• The treatment period is defined as the earliest prescription dispensing date in the measurement year for any statin medication of at least moderate intensity through the last day of the measurement year. Help patients with diabetes understand they are more likely to develop heart disease or stroke, and Statins can help reduce their chance of developing these conditions.
• Educate patients on the importance of statin medication adherence.
• 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 is depended on pharmacy claims.
  • Encourage member to obtain 90 days supplies at their pharmacy. 
  • Consider adding directives to prescriptions instructing the pharmacy to run it through the patient’s pharmacy benefit. 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

Required Exclusions:

• Palliative Care
• Members in hospice or using hospice services anytime during the measurement year.
• Members who died any time during the measurement year.
• Members 66 years of age and older as of December 31 of the measurement year (all product lines) with frailty and advanced illness.
• Medicare members 66 years of age and older by the end of the measurement period who meet either of the following:
  
  • Enrolled in an Institutional SNP (I-SNP)
  • Living in Long Term Care
• Members without a diagnosis of diabetes in any setting and a diagnosis of polycystic ovarian syndrome, gestational diabetes or steroid-induced diabetes during the measurement year or the year prior.
• Myalgia or rhabdomyolysis caused by a statin any time during the member’s history through December 31 of the measurement year.

Any time during the measurement year or the prior year:

• Members with a diagnosis of pregnancy
• In vitro fertilization
• Dispensed at least one prescription for clomiphene
• ESRD or dialysis
• Cirrhosis

During the year prior to the Measurement Year:

• Coronary artery bypass grafting (CABG)
• Myocardial infarction
• Old Myocardial Infraction
• Other revascularization procedure
• Percutaneous coronary intervention (PCI)

During the Measurement Year:

• Myalgia
• Myositis
• Myopathy
• Rhabdomyolysis

During both the Measurement Year and the year prior to the Measurement Year:

• A diagnosis of ischemic vascular disease IVD.

Exclusion Codes

Common diagnosis codes for exclusion:

• Muscular Pain 
  • 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
  • Cirrhosis 
  • ICD-10-CM: K70.30, K70.31, K71.7, K74.3, K74.4, K74.5, K74.60, K74.69, P78.81
• ESRD 
  • ICD-10-CM: N18.5, N18.6, Z99.2

Measure Medications

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

High, Moderate and Low-Intensity Statin Medications

Diabetes Medications