HEDIS RESOURCE GUIDE Adult

Transcription

1 HEDIS RESOURCE GUIDE Adult What is HEDIS? 1 HEDIS Reference Guide for Adults 2 Adult Preventive Health Care Guidelines for Providers 20 Adult HEDIS Measures 26 Pregnancy HEDIS Measures 32 How to Be a Quality Star 33 Medicare STAR Measures Pharmacy Tip Sheet Consumer Assessment of Healthcare Providers and Systems (CAHPS)

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3 WHAT IS HEDIS? HEDIS (Healthcare Effectiveness Data and Information Set) consists of a set of performance measures utilized by more than 90 percent of American health plans that compare how well a plan performs in these areas: Quality of care Access to care Member satisfaction with the health plan and doctors WHY HEDIS IS IMPORTANT HEDIS ensures health plans are offering quality preventive care and service to members. It also allows for a true comparison of the performance of health plans by consumers and employers. VALUE OF HEDIS TO YOU, OUR PROVIDERS HEDIS can help save you time while also potentially reducing health care costs. By proactively managing patients care, you are able to effectively monitor their health, prevent further complications and identify issues that may arise with their care. HEDIS can also help you: Identify noncompliant members to ensure they receive appropriate treatment and follow-up care Understand how you compare with other WellCare providers as well as with the national average VALUE OF HEDIS TO YOUR PATIENTS, OUR MEMBERS HEDIS ensures that members will receive optimal preventive and quality care. It gives members the ability to review and compare plans scores, helping them to make informed health care choices. WHAT YOU CAN DO Encourage your patients to schedule health care visits and required metabolic testing Remind your patients to follow up with ordered tests Complete outreach calls to noncompliant members. If you have questions about HEDIS or need more information, please contact your local Provider Relations representative or Quality Practice Advisor (QPA). HEDIS is a registered trademark of the National Committee for Quality Assurance (NCQA) Source: HEDIS Adult Resource Guide 1

4 HEDIS REFERENCE GUIDE FOR ADULTS The following diagnosis and/or procedure codes in the HEDIS Quick Reference Guide are in compliance with the HEDIS 2017 Volume 2 Technical Specifications. Reimbursement for these services will be in accordance with the terms and conditions of your provider agreement. The ICD-10 codes listed are effective as of October 1, ICD-9 codes are included for certain measures because they remain in effect for 2017 HEDIS. PREVENTION AND SCREENING Chlamydia Screening in Women: Percentage of women years of age who were identified as sexually active and who had at least one test for Chlamydia during the measurement year. Sexually active members may be identified either through dispensed contraceptive prescriptions (pharmacy data) or an encounter/claim indicating sexual activity during the measurement year. CPT Codes 87110, 87270, 87320, 87490, , Cervical Cancer Screening: The percentage of women years of age who were screened for cervical cancer using either of the following criteria: Women age who had cervical cytology performed every 3 years. Women age who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years. Cervical Cytology: , 88147, 88148, 88150, 88152, 88153, 88154, , 88174, CPT Codes HPV Tests: , 87624, Cervical Cytology: G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 HPV Tests: G0476 Exclusion Criteria: Women who had a hysterectomy with no residual cervix, cervical agenesis or acquired absence of cervix any time during the member's history through Dec. 31 of the measurement year , 56308, 57540, 57545, 57550, 57555, 57556, 58150, 58152, 58200, 58210, 58240, 58260, 58262, 58263, 58267, 58270, CPT Codes 58275, 58280, 58285, , 58548, 58550, , , 58951, 58953, 58954, 58956, ICD-9-CM Diagnosis 618.5, , V88.01, V88.03 ICD-9-CM Procedure 68.41, 68.49, 68.51, 68.59, 68.61, 68.69, 68.71, 68.79, 68.8 Q51.5, Z90.710, Z ICD-10-CM Procedure 0UTC0ZZ, 0UTC4ZZ, 0UTC7ZZ, 0UTC8ZZ Adult BMI Assessment: Percentage of members years of age who had an outpatient visit and who had their body mass index (BMI) documented during the measurement year or the year prior to the measurement year. For members younger than 20, the BMI must be represented as a percentile. BMI Values: V85.0, V85.1, V85.21-V85.25, V85.30-V85.39, V85.41 V85.45 ICD-9-CM Diagnosis BMI Percentile: V85.51-V85.54 BMI Values (20 years and older): Z68.1, Z68.20-Z68.39, Z68.41-Z68.45 BMI Percentile (<20 years old): Z68.51-Z68.54 Breast Cancer Screening: Percentage of women years of age who had one or more mammograms to screen for breast cancer any time on or between October 1 two years prior to the measurement year, and December 31 of the measurement year. This measure evaluates primary screening, not diagnostic screenings. CPT Codes G0202 ICD-9-CM Procedure 87.36, Exclusion Criteria: Members who have a diagnosis of bilateral mastectomy Bilateral mastectomy ICD-9-CM Procedure 85.42, 85.44, 85.46, ICD-10-CM Procedure 0HTV0ZZ Unilateral mastectomy Modifiers Absence of Breast History of Bilateral Mastectomy ICD-9-CM Procedure ICD-10-Procedure CPT CPT 85.41, 85.43, 85.45, Right Unilateral Mastectomy: 0HTT0ZZ Left Unilateral Mastectomy: 0HTU0ZZ 19180, 19200, 19220, 19240, Bilateral: 50, 09950; Right: RT; Left: LT Right Breast: Z90.11 Left Breast: Z90.12 Z HEDIS Adult Resource Guide 2

5 Colorectal Cancer Screening: Percentage of members years of age who had appropriate screening for colorectal cancer. Appropriate screenings are defined by one of the following: Annual FOBT or FIT during the measurement year. Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year. Colonoscopy during the measurement year or the nine years prior to the measurement year. FOBT 82270, CPT Codes FIT Flexible Sigmoidoscopy , , , 45349, Colonoscopy , 44397, , 45355, , FOBT G0328 Flexible Sigmoidoscopy G0104 Colonoscopy G0105, G0121 ICD-9-CM Procedure Flexible Sigmoidoscopy Colonoscopy 45.22, 45.23, 45.25, 45.42, Exclusion Criteria: Members with a diagnosis of colorectal cancer or total colectomy are excluded. CPT Codes Total colectomy , , Colorectal cancer G0213-G0215, G0231 ICD-9-CM Diagnosis Colorectal cancer , 154.0, 154.1, 197.5, V10.05, V10.06 Colorectal cancer C18.0-C18.9, C19, C20, C21.2, C21.8, C78.5, Z85.038, Z ICD-9-CM Procedure Total colectomy ICD-10-CM Procedure Total colectomy 0DTE0ZZ, 0DTE4ZZ, 0DTE7ZZ, 0DTE8ZZ Care for Older Adults: Percentage of adults 66 years and older who had each of the following during the measurement year: Advance care planning Presence of an advance care plan; (e.g., living will, health care power of attorney, health care proxy, actionable medical orders, or surrogate decision maker); or documentation of an advance care planning discussion and date; (the documentation must be noted in the measurement year); or notation in the medical record that the member previously executed an advance care plan. Medication review At least one medication review conducted by a prescribing practitioner or clinical pharmacist during the measurement year and the presence of a medication list (list must be signed and dated by the appropriate practitioner or clinical pharmacist during the measurement year) in the medical record. Functional status assessment Documentation must include evidence of a complete functional status assessment and the date completed. Pain screening Documentation must include an assessment for pain (which may include positive or negative findings) or the result of an assessment using a standardized tool and the date the assessment was completed. Advanced Care Planning Medication Review 90863, 99605, CPT Codes Transition of Care 7 Days Transition of Care 14 Days Advance Care Planning 1157F, 1158F Medication Review 1160F CPT II Codes Medication List 1159F Functional Status Assessment 1170F Pain Screening 1125F, 1126F Advance Care Planning - S0257 Medication List G HEDIS Adult Resource Guide 3

6 UTILIZATION Adolescent Well-Care Visits: Percentage of members years of age who had at least one comprehensive well-care visit with a PCP or OB/GYN during the measurement year. Documentation must contain evidence of the following: health and developmental history (physical and mental), a physical exam, and health education/anticipatory guidance required and the date visit are completed. ICD-9-CM Diagnosis V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, Z00.8, Z02.0, Z02.1, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9 CPT Codes 99384, 99385, 99394, G0438, G0439 ACCESS/AVAILABILITY OF CARE Annual Dental Visits: Percentage of members 2 20 years of age who had at least one dental visit during the measurement year. This measure applies only if dental care is a covered benefit in the organization s Medicaid contract. CPT 70300, 70310, 70320, 70350, D0120-D0999, D1110-D1999, D2140-D2999, D3110-D3999, D4210-D4999, D5110-D5899, D5994, D6010-D6205, D7111-D7999, CDT D8010-D8999, D9110-D9999 Adults Access to Preventive/Ambulatory Health Services Percentage of members 20 years of age and older who had an ambulatory or preventive care visit during the measurement year. Office Visit/ Outpatient Services: , , Home Services: , Nursing facility care: , 99315, 99316, CPT Custodial care services: , Preventive medicine: , , , 99411, 99412, 99420, Ophthalmology and optometry: 92002, 92004, 92012, Preventive medicine: G0402, G0438, G0439 Outpatient/Clinic Visits: G0463, T1015 Ophthalmology and optometry: S0620, S0621 ICD-9 Diagnosis General Medical Exam: V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 General Medical Exam: Z00.00, Z00.01 Other Exams: Z00.5, Z00.8, Z02.0, Z02.2, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z02.9 Prenatal Care: Percentage of deliveries that received a prenatal care visit in the first trimester or within 42 days of enrollment. Frequency of Ongoing Prenatal Care: Percentage of deliveries that had the expected prenatal visits. 640.x3, 641.x3, 642.x3, 643.x3, 644.x3, 645.x3, 646.x3, 647x.3, 648.x3, 649.x3, 651.x3, 652.x3, 653.x3, 654.x3, 655.x3, 656.x3, ICD-9-CM Diagnosis 657.x3, 658.x3, 659.x3, 678.x3, 679.x3, V22.0-V22.2, V23.0-V23.3, V23.41, V23.42, V23.49, V23.5, V23.7, V23.8x, V23.9, V28.0 V28.6, V28.81, V28.82, V28.89, V28.9 ICD-9 Procedure Ultrasonography: Use appropriate code family: O Z03.7, Z03.7x, Z33, Z33.1, Z33.2, Z34, Z34.0, Z34.0x, Z34.8, Z34.8x, Z34.9, Z34.9x, Z36 ICD-10-CM Procedure Ultrasonography: BY49ZZZ, BY4BZZZ, BY4CZZZ, BY4DZZZ, BY4FZZZ, BY4GZZZ E/M: , , , OB Fetal Monitoring: 76801, 76805, 76811, 76813, , CPT Codes OB Panel: 80055, TORCH: 86644, 86694, 86695, 86696, 86762, 86777, ABO/Rh: 86900, CPT II Codes 0501F, 0502F H1000-H1004 Outpatient and Clinic Visits: G0463, T HEDIS Adult Resource Guide 4

7 Postpartum Care: The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery. ICD-9-CM Diagnosis V24.1, V24.2, V25.11-V25.13, V72.31, V72.32, V76.2 ICD-9-CM Procedure Z01.411, Z01.419, Z01.42, Z30.430, Z39.1, Z39.2 CPT Codes 57170, 58300, 59430, , 88147, 88148, 88150, , , 88174, 88175, CPT II Codes 0503F RESPIRATORY CONDITIONS G0101, G0123, G0124, G0141, G0143-G0145, G0147, G0148, P3000, P3001, Q0091 Medication Management for People with Asthma: Percentage of members 5 85 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported: Percentage of members who remained on an asthma controller medication for at least 50% of their treatment period. Percentage of members who remained on an asthma controller medication for at least 75% of their treatment period. ICD-9-CM Diagnosis , , , , , , J45.20-J45.22, J45.30-J45.32, J45.40-J45.42, J45.50-J45.52, J J45.902, J45.909, J45.990, J45.991, J CPT , , , , , 99238, 99239, , , , 99291, , , , 99420, 99429, 99455, G0402, G0438, G0439, G0463, T1015 FDA-Approved Asthma Medications: For the complete list of FDA-approved asthma medications and NDC codes, please visit (to be posted by Nov. 1, 2016). Antiasthmatic combinations Antibody inhibitor Inhaled steroid combinations Inhaled corticosteroids Leukotriene modifiers Mast cell stabilizers Methylxanthines Short Acting, Inhaled beta-2 agonist Dyphylline-guaifenesin Guaifenesin-theophylline Omalizumab Budesonide-formoterol Fluticasone-salmeterol Mometasone-formoterol Beclomethasone Budesonide Ciclesonide Flunisolide Fluticasone CFC free Mometasone Montelukast Zafirlukast Zileuton Cromolyn Aminophylline Dyphylline Theophylline Albuterol Levalbuterol Pirbuterol Exclusion Criteria: Members with any diagnosis of emphysema, COPD, Obstructive Chronic Bronchitis, Chronic Respiratory Conditions Due to Fumes/Vapors, Cystic Fibrosis, Acute Respiratory Failure are excluded. Or, members who had no asthma controller medications dispensed during the measurement year HEDIS Adult Resource Guide 5

8 ICD-9-CM Diagnosis Emphysema 492.0, COPD , 496 Obstructive Chronic Bronchitis Chronic Respiratory Conditions Cystic Fibrosis , Acute Respiratory Other Emphysema 518.1, Emphysema J43.0, J43.1, J43.2, J43.8, J43.9 COPD J44.0, J44.1, J44.9 Chronic Respiratory Conditions J68.4 Cystic Fibrosis E84.0, E84.11, E84.19, E84.8, E84.9 Acute Respiratory J96.00, J96.01, J96.02, J96.20, J96.21, J96.22 Other Emphysema J98.2, J98.3 Asthma Controller Medications: For the complete list of asthma controller medications and NDC codes, please visit (to be posted by Nov. 1, 2016). Description Prescriptions Antiasthmatic Dyphylline-guaifenesin Guaifenesin-theophylline combinations Antibody inhibitor Omalizumab Inhaled steroid combinations Inhaled corticosteroids Leukotriene modifiers Mast cell stabilizers Methylxanthines Budesonide-formoterol Fluticasone-salmeterol Beclomethasone Budesonide Ciclesonide Montelukast Zafirlukast Cromolyn Aminophylline Dyphylline Mometasone-formoterol Flunisolide Fluticasone CFC free Mometasone Zileuton Theophylline Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis: Percentage of adults years of age seen in an ED, Outpatient, or Observation setting with a diagnosis of acute bronchitis who were not dispensed an antibiotic prescription. ICD-9-CM Diagnosis J20.3-J20.9 CPT , , , , , , , , , , 99420, 99429, 99455, G0402, G0438, G0439, G0463, T1015 Use of Spirometry testing in COPD: Percentage of adults 40 and older seen in an ED, Outpatient, or Observation setting with a new diagnosis of COPD or newly active COPD, who received appropriate spirometry testing to confirm the diagnosis. May include diagnoses of emphysema or chronic bronchitis. ICD-9-CM Diagnosis COPD: , 496 Emphysema: 492.0, Chronic Bronchitis: 491.0, 491.1, , 491.8, COPD: J44.0, J44.1, J44.9 Emphysema: J43.0, J43.1, J43.2, J43.8, J43.9 Chronic Bronchitis: J41.0, J41.1, J41.8, J42 CPT Visit Setting: , , , , , , , , , , 99420, 99429, 99455, Spirometry: 94010, , 94060, 94070, 94375, G0402, G0438, G0439, G0463, T HEDIS Adult Resource Guide 6

9 Pharmacotherapy Management of COPD Exacerbation: Percentage of COPD exacerbations for members 40 years of age and older who had an acute inpatient discharge or ED encounter on or between January 1 November 30 of the measurement year and who were dispensed appropriate medications. Two rates are reported: Dispensed a systemic corticosteroid (or there was evidence of an active prescription) within 14 days of the event Dispensed a bronchodilator (or there was evidence of an active prescription) within 30 days of the event COPD: , 496 ICD-9-CM Diagnosis: Emphysema: 492.0, Chronic Bronchitis: 491.0, 491.1, , 491.8, COPD: J44.0, J44.1, J44.9 Emphysema: J43.0, J43.1, J43.2, J43.8, J43.9 Chronic Bronchitis: J41.0, J41.1, J41.8, J42 CPT ED: Bronchodilators and Systemic Corticosteroids: For a comprehensive list and NDC codes, please visit (to be posted by Nov. 1, 2016). Aclidinium bromide Albuterol-ipratropium Anticholinergic agents Ipratropium Tiotropium Umeclidinium Albuterol Metaproterenol Arformoterol Mometasone-formoterol Budesonide-formoterol Olodaterol hydrochloride Fluticasone-salmeterol Olodaterol-tiotropium Beta 2-agonists Fluticasone-vilanterol Pirbuterol Formoterol Salmeterol Indacaterol Umeclidinium-vilanterol Levalbuterol Aminophylline Dyphylline Methylxanthines Dyphylline-guaifenesin Guaifenesin-theophylline Theophylline Betamethasone Prednisolone Dexamethasone Prednisone Glucocorticoids Hydrocortisone Triamcinolone Methylprednisolone BEHAVIORAL HEALTH FIRST-YEAR MEASURE Follow-up After Emergency Department Visit for Mental Illness (FUM): The percentage of emergency department (ED) visits for members 6 years of age and older with a principal diagnosis of mental illness, who had a follow-up visit for mental illness. Two rates are reported: 1. The percentage of ED visits for which the member received follow-up within 30 days of the ED visit. 2. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit. The follow-up visit after the ED visit can be with any practitioner. ICD-9-CM Diagnosis 290.0, 290.1x x, 290.8, 290.9, 293.0, 293.1, , , 293.9, 294.0, , , , , 294.8, 294.9, , 295.0x-295.9x, , 296.1x-296.6x, 296.7, , , , , 297.0, 297.1, 297.2, 297.3, 297.8, 297.9, 298.0, 298.1, 298.2, 298.3, 298.4, 298.8, 298.9, , , , , , , , , , , , , 300.3, 300.4, 300.5, 300.6, 300.7, , , , 300.9, 301.0, 301.1x-301.2x, 301.3, 301.4, , , , 301.6, 301.7, , , 301.9, 302.0, 302.1, 302.2, 302.3, 302.4, , 302.6, , , , , 302.9, 306.0, 306.1, 306.2, 306.3, 306.4, 306.4, , , 306.6, 306.7, 306.8, 306.9, 307.0, 307.1, , 307.3, , , 307.6, 307.7, , , , 307.9, 308.0, 308.1, 308.2, 308.3, 308.4, 308.9, 309.1, , , , 309.3, 309.4, , , 309.9, 310.0, 310.1, 310.2, , , 310.9, 311, , , , , , 312.4, , , , 312.9, 313.0, 313.1, , , , 313.9, , , 314.1, 314.2, 314.8, 314.9, , , 315.1, 315.2, , , 315.4, 315.5, 315.8, 315.9, 316 Use the appropriate code family: F 2017 HEDIS Adult Resource Guide 7

10 CPT Follow-up visits identified by the following CPT or codes with any practitioner within 7 and 30 days of ED Visit. Stand Alone Visits: , 99078, , , , , , , , , , 99411, 99412, 99495, 99496, Telehealth: , CPT Stand Alone Visits: G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010 H2020, M0064, S0201, S9480, S9484, S9485, T1015 POS Follow-up visits identified by the following CPT with POS codes with any practitioner within 7 and 30 days of ED Visit. Follow-Up Group 1: 90791, 90792, , , 90845, 90847, 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 WITH 90849, 90853, , 90875, Follow-Up Group 2: , , 99238, 99239, WITH 52, 53 FIRST-YEAR MEASURE Follow-up After Emergency Department Visit for Alcohol and Other Drug Dependence (FUA): The percentage of emergency department (ED) visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) dependence, who had a follow up visit for AOD. Two rates are reported: 1. The percentage of ED visits for which the member received follow-up within 30 days of the ED visit. 2. The percentage of ED visits for which the member received follow-up within 7 days of the ED visit. The follow-up visit after the ED visit can be with any practitioner. AOD: , , , , 291.9, , , , , , , , , , , , ICD-9-CM Diagnosis , , , , , , , , , , , , Use the appropriate code family: F CPT Follow-up visits identified by the following CPT or codes with any practitioner within 7 and 30 days of ED Visit. Stand Alone Visits: , 99078, , , , , , , , , ,99408, 99409, 99411, 99412, Telehealth: , CPT Stand Alone Visits: , 99078, , , , , , , , , ,99408, 99409, 99411, 99412, Telehealth: , POS Follow-up visits identified by the following CPT with POS codes with any practitioner within 7 and 30 days of ED Visit. Follow-Up Group 1: 90791, 90792, , , 90845, 90847, 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 WITH 90849, 90853, , 90875, Follow-Up Group 2: , , 99238, 99239, WITH 52, 53 Follow-Up After Hospitalization for Mental Illness: Percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental health disorders and who had a follow-up visit with a mental health practioner. Two rates are reported: The percentage of discharges with a follow-up within 30 days of discharge. The percentage of discharges with a follow-up within 7 days of discharge. ICD-9-CM Diagnosis , 300.3, 300.4, 301.0, 301.1x, 301.2x, 301.3, 301.4, 301.5x, 301.6, 301.7, 301.8x, 301.9, 308.x, 309.0, 309.1, 309.2x, 309.3, 309.4, 309.8x, 309.9, 311, Use the appropriate code family: F CPT Follow-up visits identified by the following CPT or codes must be with a mental health practitioner within 7 and 30 days of discharge. Stand Alone Visits: , 99078, , , , , , , , , , 99411, 99412, G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 Transitional Care: (14 Days, used for 30-Day Follow-up indicator) and (7 Days) CPT POS Follow-up visits identified by the following CPT/POS codes must be with a mental health practitioner , 90792, , , 90845, 90847, 90849, 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 WITH 90853, , 90875, , , 99238, 99239, WITH 52, HEDIS Adult Resource Guide 8

11 Antidepressant Medication Management: Percentage of members 18 years of age and older who were diagnosed with an episode of major depression and treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported: Effective Acute Phase Treatment Percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 84 days (12 weeks) Effective Continuation Phase Treatment Percentage of newly diagnosed and treated members who remained on an antidepressant medication for at least 180 days (6 months) ICD-9-CM Diagnosis , , 298.0, 311 F32.0-F32.4, F32.9, F33.0-F33.3, F33.41, F33.9 CPT AMM Stand Alone Visits: , 99078, , , , , , , , , , 99411, 99412, ED Visits: CPT AMM Visits: 90791, 90792, , , 90845, 90847, 90849, 90853, , 90875, 90876, , , 99238, 99239, AMM Stand Alone Visits: G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, M0064, S0201, S9480, S9484, S9485, T1015 WITH POS AMM Visits: 03, 05, 07, 09, 11-20, 22, 24, 33, 49, 50, 52, 53, 71, 72 Antidepressant Medications: For a comprehensive list of medications and NDC codes, please visit (to be posted by Nov. 1, 2016). Miscellaneous antidepressants Monoamine oxidase inhibitors Phenylpiperazine antidepressants Psychotherapeutic antidepressants SNRI antidepressants SSRI antidepressants Tetracyclic antidepressants Tricyclic antidepressants Bupropion Vilazodone Vortioxetine Isocarboxazid Phenelzine Selegiline Tranylcypromine Nefazodone Trazodone Amitriptyline-chlordiazepoxide Amitriptyline-perphenazine Fluoxetine-olanzapine Desvenlafaxine Duloxetine Levomilnacipran Venlafaxine Citalopram Escitalopram Fluoxetine Maprotiline Mirtazapine Amitriptyline Amoxapine Clomipramine Desipramine Doxepin (>6 mg) Fluvoxamine Paroxetine Sertraline Imipramine Nortriptyline Protriptyline Trimipramine Diabetes Screening for People with Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications: Percentage of members ages with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test. Schizophrenia: 295.0x-295.9x ICD-9 CM Diagnosis Bipolar Disorder: 296.0x, 296.1x, 296.4x, 296.5x, 296.6x, Other Bipolar Disorders: , Schizophrenia: F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 Bipolar Disorder: F30.10-F30.13, F30.2, F30.3, F30.4, F30.8, F30.9, F31.0, F31.10-F31.13, F31.2, F31.30-F31.32, F31.4, F31.5, F31.60 F31.64, F31.70-F31.78 Other Bipolar Disorders: F31.81, F31.89, F31.9 CPT 80047, 80048, 80050, 80053, 80069, 82947, 82950, 82951, 83036, CPT II 3044F, 3045F, 3046F 2017 HEDIS Adult Resource Guide 9

12 Antipsychotic Medications: For a complete list of medications and NDC codes, please visit (to be posted by Nov. 1, 2016). Miscellaneous antipsychotic agents Phenothiazine antipsychotics Psychotherapeutic combinations Thioxanthenes Long-acting injections Aripiprazole Asenapine Brexpiprazole Cariprazine Clozapine Haloperidol Iloperidone Loxapine Lurisadone Chlorpromazine Fluphenazine Perphenazine Perphenazine-amitriptyline Fluoxetine-olanzapine Thiothixene Aripiprazole Fluphenazine decanoate Haloperidol decanoate Olanzapine Paliperidone palmitate Risperidone Molindone Olanzapine Paliperidone Pimozide Quetiapine Quetiapine fumarate Risperidone Ziprasidone Prochlorperazine Thioridazine Trifluoperazine Diabetes Monitoring for People with Diabetes and Schizophrenia: The percentage of members ages with schizophrenia and diabetes who had both an LDL-C and an HbA1c test. ICD-9-CM Diagnosis Schizophrenia: 295.0x-295.9x Diabetes: 250.0x-250.9x, 357.2, 362.0x, , 648.0x Schizophrenia: F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 Diabetes: Use the appropriate code family: E or O (pre-existing DM in pregnancy) CPT HbA1c tests: 83036, LDL-C tests: 80061, 83700, 83701, 83704, CPT II 3044F, 3045F, 3046F, 3048F, 3049F, 3050F Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia: The percentage of members ages with schizophrenia and cardiovascular disease, who had an LDL-C test during the measurement year. Cardiovascular disease may be identified either by event or diagnosis. Schizophrenia: 295.0x-295.9x Ischemic Vascular Disease (IVD): 411.0, 411.1, , , 413.0, 413.9, , , 414.8, 414.9, 429.2, , ICD-9-CM Diagnosis , , , , , , , , , , , , , , , , , 437.0, 440.0, 440.1, , , 440.4, 440.8, 440.9, , , 444.1, , , , , 444.9, , , , Schizophrenia: F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9 Ischemic Vascular Disease (IVD): Use the appropriate code family: I CPT LDL-C Tests: 80061, 83700, 83701, 83704, CPT II LDL-C Tests: 3048F, 3049F, 3050F Adherence to Antipsychotic Medications for Individuals with Schizophrenia: This CMS measure has been adapted for use in HEDIS. The percentage of members ages during the measurement year with schizophrenia who were dispensed and remained on an antipsychotic medication for at least 80% of their treatment period. ICD-9-CM Diagnosis 295.0x-295.9x F20.0-F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F day supply: J day supply: J0401, J1631, J2358, J2426, J HEDIS Adult Resource Guide 10

13 Antipsychotic Medications: For a complete list of medications and NDC codes, please visit (to be posted by Nov. 1, 2016). Description Prescription Days Supply Miscellaneous antipsychotic agents (oral) Phenothiazine antipsychotics (oral) Psychotherapeutic combinations (oral) Thioxanthenes (oral) Long-acting injections Aripiprazole Asenapine Brexpiprazole Cariprazine Clozapine Haloperidol Iloperidone Loxapine Lurisadone Molindone Chlorpromazine Fluphenazine Perphenazine Perphenazine-amitriptyline Fluoxetine-olanzapine Thiothixene Aripiprazole Fluphenazine decanoate Haloperidol decanoate Risperidone Olanzapine Paliperidone Pimozide Quetiapine Quetiapine fumarate Risperidone Ziprasidone Prochlorperazine Thioridazine Trifluoperazine Olanzapine Paliperidone palmitate Exclusions include members who met at least one of the following during the measurement year: 28-day supply 14-day supply Dementia diagnosis. Did not receive at least two (2) antipsychotic medication dispensing events , 290.1x, , , 290.3, , 290.8, 290.9, 291.2, , 294.0, , , , , 331.0, ICD-9-CM Diagnosis Use the appropriate code family: F, G CARDIOVASCULAR CONDITIONS Controlling High Blood Pressure: Percentage of members years of age who had a diagnosis of hypertension (HTN) in the medical recod anytime during the member's history on or before June 30 of the measurement year, and whose BP was adequately controlled (ages BP <140/90, ages with diabetes BP< 140/90, ages without diabetes BP<150/90) during the measurement year. HTN diagnoses include: Hypertension, HTN, High BP (HBP), Elevated BP ( BP), Borderline HTN, Intermittent HTN, History of HTN, Hypertensive vascular disease (HVD), Hyperpiesia, Hyperpiesis HTN: 401.0, 401.1, ICD-9-CM Diagnosis Diabetes: 250.0x-250.9x, 357.2, 362.0x, , 648.0x HTN: I10 Diabetes: Use the appropriate code family: E or O (pre-existing DM in pregnancy) G0402, G0438, G0439, G0463, T , , , , , , , , CPT Codes 99397, , 99411, 99412, 99420, 99429, 99455, Persistence of Beta-Blocker Treatment After a Heart Attack: Percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged alive from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge. ICD-9-CM Diagnosis: 410.x1 I21.01, I21.02, I21.09, I21.11, I21.19, I21.21, I21.29, I21.3, I21.4 Beta Blockers: For a comprehensive list of medications and NDC codes, please visit (to be posted by Nov. 1, 2016). Cardioselective beta-blockers Acebutolol Atenolol Betaxolol Bisoprolol Metoprolol Nebivolol 2017 HEDIS Adult Resource Guide 11

14 Noncardioselective beta-blockers Antihypertensive combinations Carvedilol Labetalol Nadolol Penbutolol Atenolol-chlorthalidone Bendroflumethiazide-nadolol Bisoprolol-hydrochlorothiazide Pindolol Propranolol Sotalol Timolol Hydrochlorothiazide-metoprolol Hydrochlorothiazide-propranolol Statin Therapy for Patients with Cardiovascular Disease: The percentage of males ages and females ages during the measurement year who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and who meet the following criteria: Received Statin Therapy. Members who were dispensed at least one high or moderate-intensity statin medication during the measurement year. Statin Adherence 80%. Members who remained on a high or moderate-intensity statin medication for at least 80% of the treatment period. Member may be identified in two ways: by event (i.e., discharged from inpatient setting with MI diagnosis; or these events in any setting: CABG; PCI; or other revascularization procedure) prior to the measurement year; or, by diagnosis (IVD) in an outpatient setting or acute inpatient encounter for both the measurement year and the year prior. Exclusion criteria include pregnancy, in vitro fertilization, ESRD, Cirrhosis, Myalgia, myositis, or rhabdomyolysis, or at least one prescription for clomiphene dispensed during the measurement year or the year prior. ICD-9-CM Diagnosis IVD: 411.0, 411.1, , , 413.0, 413.9, , 414.2, 414.3, 414.4, 414.8, 414.9, 429.2, , , , , , , , , , , , , , , , , , , 437.0, 440.0, 440.1, , , 440.4, 440.8, 440.9, , , 444.1, , , , , 444.9, , , , IVD: Use the appropriate code family: I High and Moderate-Intensity Statin Medications: For a comprehensive list of medications and NDC codes, please visit (to be posted by Nov. 1, 2016). Atorvastatin mg Amlodipine-atorvastatin mg Ezetimibe-atorvastatin mg High-intensity statin therapy Rosuvastatin mg Simvastatin 80 mg Ezetimibe-simvastatin 80 mg Atorvastatin mg Sitagliptin-simvastatin mg Amlodipine-atorvastatin mg Pravastatin mg Ezetimibe-atorvastatin mg Lovastatin 40 mg Moderate-intensity statin Rosuvastatin 5 10 mg Niacin-lovastatin 40 mg therapy Simvastatin mg Fluvastatin XL 80 mg Ezetimibe-simvastatin mg Fluvastatin 40 mg bid Niacin-simvastatin mg Pitavastatin 2 4 mg 2017 HEDIS Adult Resource Guide 12

15 DIABETES Comprehensive Diabetes Care (CDC): The percentage of members years of age with diabetes (Type 1 and Type 2) who had each of the following: Hemoglobin A1c (HbA1c) testing (i.e., A1c, HbA1c, HgbA1c, Hemoglobin A1c, Glycohemoglobin A1c, Glycohemoglobin, Glycated hemoglobin, Glycosylated hemoglobin) HbA1c poor control (>9.0%) HbA1c control (<8.0%) HbA1c control (<7.0%)- exclude those 65 years of age* Eye exam (retinal) performed by an eye care provider Medical attention for nephropathy either evidence of nephrology or a nephropathy screen BP control (<140/90 mm Hg) *Additional exclusion criteria are required for this indicator: CABG or PCI, IVD, CHF, Prior MI, Thoracic Aortic Aneurysm, ESRD, CKD (stage 4), CRF, Dementia, Blindness, Amputation of lower extremity. ICD-9-CM Diagnosis Diabetes: 250.0x-250.9x, 357.2, 362.0x, , 648.0x Diabetes: Use the appropriate code family: E or O (pre-existing DM in pregnancy) HbA1C Testing CPT Codes 83036, CPT II Codes 3044F (<7.0%), 3045F ( ), 3046F (>9%) Urine Macroalbumin CPT Codes , 81005, , CPT II Codes 3060F-3062F Evidence of Treatment for Nephropathy ICD- 9-CM Diagnosis Use the appropriate code family: E, I, N, Q, R CPT II Codes 3066F, 4010F Evidence of Stage 4 Chronic Kidney Disease ICD-9-CM Diagnosis N18.4 Evidence of End Stage Renal Disease (ESRD) ICD-9-CM Diagnosis 585.5, 585.6, V45.11, V45.12 ICD-9 Procedure 38.95, 39.27, 39.42, 39.43, 39.53, , N18.5, N18.6, Z91.15, Z99.2 ICD-10 Procedure 3E1M39Z, 5A1D00Z, 5A1D60Z 36147, 36800, 36810, 36815, 36818, 36819, 36820, 36821, , 90935, 90937, 90940, 90945, 90947, , CPT 90965, 90966, 90969, 90970, 90989, 90993, 90997, 90999, G0257, S9339 POS 65 Evidence of Kidney Transplant ICD-9-CM Diagnosis V42.0 ICD-9 Procedure 55.61, Z94.0 ICD-10 Procedure 0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY10Z2 CPT 50300, 50320, 50340, 50360, 50365, 50370, S2065 ACE/ARB Therapy: For a comprehensive list of medications and NDC codes, please visit (to be posted by Nov. 1, 2016). Angiotensin converting enzyme inhibitors , , , , , , , , , , , , , , , , , , , 580.0, 580.4, , , 580.9, 581.0, 581.1, 581.2, 581.3, , , 581.9, 582.0, 582.1, 582.2, 582.4, , , 582.9, 583.0, 583.1, 583.2, 583.4, 583.6, 583.7, , , 583.9, 584.5, 584.6, 584.7, 584.8, 584.9, 585.1, 585.2, 585.3, 585.9, 586, 587, 588.0, 588.1, , , 588.9, 753.0, , , Benazepril Captopril Enalapril Fosinopril Lisinopril Moexipril Perindopril Quinapril Ramipril Trandolapril 2017 HEDIS Adult Resource Guide 13

16 Angiotensin II inhibitors Antihypertensive combinations Azilsartan Candesartan Eprosartan Irbesartan Aliskiren-valsartan Amlodipine-benazepril Amlodipine-hydrochlorothiazide-valsartan Amlodipine-hydrochlorothiazide-olmesartan Amlodipine-olmesartan Amlodipine-telmisartan Amlodipine-valsartan Azilsartan-chlorthalidone Benazepril-hydrochlorothiazide Candesartan-hyrochlorothiazide Captopril-hydrochlorothiazide Enalapril-hydrochlorothiazide Identify Systolic and Diastolic BP Levels <140/90 Systolic BP <130: 3074F; Systolic BP : 3075F; Systolic BP 140: 3077F CPT II Diastolic BP <80: 3078F; Diastolic BP 80 89: 3079F; Diastolic BP 90: 3080F Losartan Olmesartan Telmisartan Valsartan Eprosartan-hydrochlorothiazide Fosinopril-hydrochlorothiazide Hydrochlorothiazide-irbesartan Hydrochlorothiazide-lisinopril Hydrochlorothiazide-losartan Hydrochlorothiazide-moexipril Hydrochlorothiazide-olmesartan Hydrochlorothiazide-quinapril Hydrochlorothiazide-telmisartan Hydrochlorothiazide-valsartan Trandolapril-verapamil Retinal Eye Exam: Screening or monitoring for diabetic retinal disease as identified by administrative data. This includes diabetics who had one of the following: A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year. A negative retinal or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year. Medical record documentation must include who performed or reviewed the results (i.e. eye care professional (optometrist or ophthalmologist), the results, and the date when the procedure was performed. Refer to Adult HEDIS Measures at the end of the Adult Resource Guide for more notes. Diabetes Mellitus Without Complications: E10.9, E11.9, E13.9 Diabetic Retinal Screening: 67028, 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, CPT 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, , 92230, 92235, 92240, 92250, 92260, , , Diabetic Retinal Screening: 2022F, 2024F, 2026F, 3072F CPT II Diabetic Retinal Screening With Eye Care Professional: 2022F, 2024F, 2026F Diabetic Retinal Screening Negative: 3072F S0620, S0621, S3000 Statin Therapy for Patients with Diabetes: The percentage of members ages during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) and who meet the following criteria: 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 statin medication of any intensity for at least 80% of the treatment period. Exclusion criteria (event or diagnosis) include MI, CABG, PCI, any other revascularization procedure, Ischemic Vascular Disease, pregnancy, in vitro fertilization, ESRD, Cirrhosis, Myalgia, myositis, or rhabdomyolysis, or at least one prescription for clomiphene dispensed during the measurement year. ICD-9-CM Diagnosis Diabetes: 250.0x-250.9x, 357.2, 362.0x, , 648.0x Use the appropriate code family: E or O (pre-existing DM in pregnancy) High and Moderate-Intensity Statin Medications: For a comprehensive list of medications and NDC codes, please visit (to be posted by Nov. 1, 2016). Atorvastatin mg Rosuvastatin mg High-intensity statin therapy Amlodipine-atorvastatin mg Simvastatin 80 mg Ezetimibe-atorvastatin mg Ezetimibe-simvastatin 80 mg Moderate-intensity statin therapy Atorvastatin mg Amlodipine-atorvastatin mg Ezetimibe-atorvastatin mg Rosuvastatin 5 10 mg Simvastatin mg Ezetimibe-simvastatin mg Niacin-simvastatin mg Sitagliptin-simvastatin mg Pravastatin mg Lovastatin 40 mg Niacin-lovastatin 40 mg Fluvastatin XL 80 mg Fluvastatin 40 mg bid Pitavastatin 2 4 mg 2017 HEDIS Adult Resource Guide 14

17 Low-intensity statin therapy Simvastatin 10 mg Ezetimibe-simvastatin 10 mg Sitagliptin-simvastatin 10 mg Pravastatin mg Lovastatin 20 mg Niacin-lovastatin 20 mg Fluvastatin mg Pitavastatin 1 mg MUSCULOSKELETAL CONDITIONS Use of Imaging Studies for Low Back Pain: Percentage of members years old with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI or CT Scan) within 28 days of the diagnosis , , , , 722.6, , 724.2, 724.3, 724.5, 724.6, , , , 738.5, 739.3, 739.4, 846.0, ICD-9-CM Diagnosis 846.1, 846.2, 846.3, 846.8, 846.9, Use the appropriate code family: M, S CPT-Imaging Studies 72010, 72020, 72052, 72100, 72110, 72114, 72120, , 72141, 72142, , 72156, 72158, 72200, 72202, Osteoporosis Management in Women Who Had a Fracture: The percentage of women years of age who suffered a fracture and who had either a bone mineral density (BMD) test or prescription for a drug to treat or prevent osteoporosis in the six months after the fracture. Note: Fractures of finger, face and skull are not included in this measure. CPT Bone Mineral Density Test: 76977, 77078, , 77085, Bone Mineral Density Test: G0130 Osteoporosis Therapy (after fracture): J0630, J0897, J1740, J3110, J3487-J3489, Q2051 ICD-9 Procedure Bone Mineral Density Study: ICD-10 Procedure Use the appropriate procedure code family: BP, BQ, BR FDA-Approved Osteoporosis Therapies: For a complete list of medications and NDC codes, visit (to be posted by Nov. 1, 2016). Biphosphonates Other agents Alendronate Alendronate-cholecalciferol Ibandronate Risedronate Zoledronic acid Calcitonin Denosumab Raloxifene Teriparatide Disease-Modifying Anti-Rheumatic Drug Therapy for Rheumatoid Arthritis: Percentage of members 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for a disease modifying anti-rheumatic drug (DMARD). ICD-9-CM Diagnosis 714.0, 714.1, 714.2, Use the appropriate code family: M DMARD: J0129, J0135, J0717, J1438, J1600, J1602, J1745, J3262, J7502, J7515-J7518, J9250, J9260, J9310 DMARDs: For a complete list of medications and NDC codes, visit (to be posted by Nov. 1, 2016). 5-Aminosalicylates Sulfasalazine Alkylating agents Cyclophosphamide Aminoquinolines Hydroxychloroquine Anti-rheumatics Immunomodulators Immunosuppressive agents Janus Kinase (JAK) Inhibitor Tetracyclines Auranofin Gold sodium thiomalate Leflunomide Abatacept Adalimumab Anakinra Certolizumab Certolizumab pegol Azathioprine Cyclosporine Mycophenolate Tofacitinib Minocycline 2017 HEDIS Adult Resource Guide 15 Methotrexate Penicillamine Etanercept Golimumab Infliximab Rituximab Tocilizumab

18 MEDICATION MANAGEMENT Medication Reconciliation Post-Discharge: Percentage of discharges from January 1 to December 1 of the measurement year for members 18 year of age and older for whom medications were reconciled on or within 30 days of discharge (31 total days). CPT 99495, CPT II 1111F Annual Monitoring for Patients on Persistent Medications: Percentage of members 18 years of age and older who received at least 180 treatment days of ambulatory medication therapy for a select therapeutic agent during the measurement year and at least one therapeutic monitoring event for the therapeutic agent in the measurement year. Medications include ACE inhibitors or ARB, digoxin, and diuretics. Physiologic Monitoring Tests 80047, 80048, 80050, 80051, 80053, 80069, 82565, 82575, CPT Codes Digoxin Level Potentially Harmful Drug-Disease Interactions in the Elderly: Percentage of members 65 years of age and older who have evidence of an underlying disease, condition or health concern and who were dispensed an ambulatory prescription for a contraindicated medication, concurrent with or after the diagnosis. A lower rate represents a better performance. A history of falls and a prescription for anticonvulsants, nonbenziodizaepine hypnotics, SSRIs, antipsychotics, benzodiazepines or tricyclic antidepressants. Dementia and a prescription for antipsychotics, benzodiazepines, tricyclic antidepressants, H2 Receptor Antagonists, nonbenzodiazepine hypnotics or anticholinergic agents. Chronic Kidney Disease and prescription for non-aspirin NSAIDs or Cox-2 selective NSAIDs Falls E880.0, E880.1, E880.9, E884.0-E884.6, E884.9, E885.9, E887, E888.0, E888.1, E888.8, E888.9 Hip Fractures , , , , , , , 820.8, 820.9, V54.13 ICD-9-CM Diagnosis Dementia 290.0, , ,290.21, 290.3, , 290.8, 290.9, 291.2, , 294.0, , , , , 331.0, Chronic Kidney Disease and Transplant 585.4, 585.5, 585.6, V42.0, V45.11, V45.12, V54.11 ICD-9 Procedure Chronic Kidney Disease, Kidney Transplant, and ESRD 38.95, 39.27, 39.42, 39.43, 39.53, , 54.98, 55.61, Use the appropriate code family W for falls; S for Hip Fractures; F and G for Dementia; N or Z for CKD, Transplant or ESRD ICD-10 Procedure ESRD 3E1M39Z, 5A1D00Z, 5A1D60Z Kidney Transplant 0TY00Z0, 0TY00Z1, 0TY00Z2, 0TY10Z0, 0TY10Z1, 0TY10Z2 CPT Codes Chronic Kidney Disease and Transplant 36147, 36800, 36810, 36815, 36818, , , 50300, 50320, 50340, 50360, 50365, 50370, 50380, 90935, 90937, 90940, 90945, 90947, , 90970, 90989, 90993, 90997, 90999, Hip Fracture: 27230, 27232, 27235, 27236, 27238, 27240, , 27248, 27254, , Chronic Kidney Disease: G0257, S2065, S9339 POS ESRD: 65 Potentially Harmful Drugs: For a comprehensive list of medications and NDC codes, please visit (to be posted by November 1, 2016). Anticonvulsants SSRIs Antipsychotics Benzodiazepines Carbamazepine Fosphenytoin Oxcarbazepine Clobazam Gabapentin Phenobarbital Divalproex sodium Lacosamide Phenytoin Ethosuximide Lamotrigine Pregabalin Ethotoin Levetiracetam Primidone Ezogabine Mephobarbital Rufinamide Felbamate Methsuximide Tiagabine HCL Citalopram Escitalopram Aripiprazole Asenapine Brexpiprazole Cariprazine Chlorpromazine Clozapine Fluoxetine Fluvoxamine Fluphenazine Haloperidol Iloperidone Loxapine Lurasidone Molindone Paroxetine Sertraline Olanzapine Paliperidone Perphenazine Pimozide Quetiapine Risperidone Topiramate Valproate sodium Valproic acid Vigabatrin Zonisamide Thioridazine Thiothixene Trifluoperazine Ziprasidone Alprazolam Clorazepate- Lorazepam Triazolam Chlordiazepoxide dipotassium Midazolam HCL products Diazepam Oxazepam Clonazepam Estazolam Quazepam Flurazepam HCL Temazepam 2017 HEDIS Adult Resource Guide 16

19 Nonbenzodiazepine Eszopiclone hypnotics Amitriptyline Tricyclic antidepressants Amoxapine Clomipramine H2 receptor antagonists Cimetidine Anticholinergic agents, Prochlorperazine antiemetics Carbinoxamine Chlorpheniramine Anticholinergic agents, Hydroxyzine antihistamines Brompheniramine Clemastine Atropine Anticholinergic agents, Homatropine antispasmodics Belladonna alkaloids Darifenacin Anticholinergic agents, Fesoterodine antimuscarinics (oral) Solifenacin Anticholinergic agents, Benztropine anti-parkinson agents Anticholinergic agents, Cyclobenzaprine skeletal muscle relaxants Anticholinergic agents, SSRIs Paroxetine Anticholinergic agents, Disopyramide antiarrhythmic Prescriptions to Identify Members With Dementia Description Prescription Cholinesterase inhibitors Donepezil Miscellaneous central Memantine nervous system agents Cox-2 Selective NSAIDs and Nonaspirin NSAIDs Description Prescription Cox-2 Selective NSAIDs Celecoxib Diclofenac potassium Diclofenac sodium Nonaspirin NSAIDs Etodolac Fenoprofen Flurbiprofen Zaleplon Zaleplon Desipramine Desipramine Doxepin (>6 mg) Doxepin (>6 mg) Imipramine Imipramine Famotidine Nizatidine Ranitidine Promethazine Triprolidine Cyproheptadine Dimenhydrinate Diphenhydramine Meclizine Dicyclomine Hyoscyamine Propantheline Trospium Flavoxate Trihexyphenidyl Orphenadrine Galantamine Dexbrompheniramine Dexchlorpheniramine Doxylamine Scopolamine Clidiniumchlordiazepoxide Trospium Flavoxate Rivastigmine Ibuprofen Mefenamic acid Oxaprozin Indomethacin Meloxicam Piroxicam Ketoprofen Nabumetone Sulindac Ketorolac Naproxen Tolmetin Meclofenamate Naproxen sodium 2017 HEDIS Adult Resource Guide 17