Administrative bulletin: 2026-04-002 Medicare only

Date: April 1, 2026

Topics covered in this administrative bulletin are applicable to:

Professional and facility Providers

• Centers for Medicare and Medicaid services Part D stars measure - Statin Use in Persons with Diabetes.
• Medicare Part D – Stars medication adherence measures and best practices.

Unless otherwise noted, if you have any questions regarding the information in this bulletin, please contact your Provider Engagement Consultant or visit capbluecross.com/wps/portal/cap/provider/pec-look-up and enter your NPI or Tax ID to identify your designated point of contact at Capital Blue Cross.

Professional and facility Providers

Centers for Medicare and Medicaid services Part D stars measure - Statin Use in Persons with Diabetes

KEY POINT: New exclusions for Statin Use in Persons with Diabetes (SUPD) now recognize PCSK9 meds as alternative for patients who cannot tolerate statins. See also the definition for the “measurement period” outlined below. .

SUPD measure definition: Percentage of Medicare members with diabetes ages 40-75 who were dispensed at least two diabetes medication fills and received at least one fill of a statin medication during the measurement period. The measurement period begins on the fill date of the first diabetes medication of the calendar year and ends on the last date of coverage of the calendar year.

Exclusions:

New for 2026 - Patients are excluded from the measure if they fill bempedoic acid or a PCSK9 inhibitor during the measurement year and have not filled a statin.

Patients are excluded if any of the following conditions are submitted during the measurement period (see codes below):

• Received hospice care.
• End-stage renal disease.
• Cirrhosis, pre-diabetes, or polycystic ovary syndrome (PCOS).
• Rhabdomyolysis, myopathy, or related adverse effects of statin therapy.
• Are pregnant, lactating, or undergoing fertility treatment.

Except for hospice care claims, exclusions for the SUPD measure will only be captured via claims data with an appropriate ICD-10-CM code. Coding for the following qualifying exclusions must be submitted annually during an in-person or audio/video provider visit within the measurement period.

The condition does not need to occur during the measurement period. If the condition is not being treated currently but is still relevant, the member's medical chart should reflect 'history of' and be submitted with a qualified encounter to close the gap.

*These codes are intended to close Star measure gaps and do not apply to payment or reimbursement. Exclusion codes may be changed, added, or removed by CMS

**ICD-10 CM created by the National Center for Health Statistics (NCHS), under the authorization of the World Health Organization (WHO). WHO-copyright holder

Best practices and measure tips:

• Myalgia is not an exclusion code for SUPD. Myopathy, defined as 'when a toxin or medication interferes with muscle structure or function', is a qualifying SUPD exclusion.
• If intolerance to one statin occurs, consider reducing the dose or frequency or trialing an alternative statin that is more hydrophilic, such as pravastatin or rosuvastatin. If directions are modified, send an updated prescription for accurate adherence.
• SUPD is measured through prescription drug event (PDE) data. Statin must be filled through Medicare Part D coverage to be captured for the measure. Patients obtaining a statin through a pharmacy discount program typically pay more than if they used their Capital Blue Cross Medicare Part D prescription drug coverage.
• This measure overlaps with the Medication Adherence for Cholesterol (Statins) measure. Once patients demonstrate they tolerate statin therapy, 100-day supplies are encouraged.
• For patients turning 76 during the measurement year, a statin must be filled no later than the month before they turn 76 for the claim to close the SUPD gap.

Medicare Part D – Stars medication adherence measures and best practices

KEY POINT: Medication adherence is defined by CMS as obtaining timely refills and having medication on hand at least 80 percent of the time during the measurement period.

As an important part of patient care, the Centers for Medicare and Medicaid Services (CMS) evaluates medication adherence to certain diabetes, hypertension, and cholesterol medications. The following are Star adherence measures, which remain triple-weighted with Capital.

• Medication adherence for diabetes medications
• Medication adherence for hypertension (RAS Antagonists)
• Medication adherence for cholesterol (Statins)

Medications included in each measure:

Exclusions

Patients are excluded from the adherence measure if they:

• Received hospice care during the measurement year.
• Have a diagnosis of end-stage renal disease.
• Have a prescription for insulin (Diabetes measure only).
• Have a prescription for sacubitril/valsartan (Hypertension measure only).

Best practice and measure success tips:

• Encourage a 100-day supply for adherence medications when appropriate. Our Medicare plans allow for 100-day prescriptions (extended supply) at both mail-order and retail pharmacies. Our in-network pharmacies include CVS, Wal-Mart, Sam's Club, Weis, and Giant. If transportation is a barrier, our in-network home delivery pharmacies are Express Scripts and Amazon Pharmacy.
• Most of the Adherence measure medications are Tier 1 generic drugs and have a zero-cost share to members when obtained from an in-network pharmacy. Overall, members will save the most money when obtaining medications at in-network pharmacies.
• Adherence is measured through prescription drug event (PDE) data. Adherence medications must be filled through Medicare Part D coverage to be captured for the adherence measures. Patients who obtain adherence measure medications through a pharmacy discount program or 'cash claim' will pay more than if filled under Capital MAPD prescription drug coverage.
• Ensure directions on the prescription are accurate and specific for proper calculation of days' supply by the pharmacy. Avoid “As Directed” directions.
• If a gap is identified for an adherence measure medication, verify current dosing for the medication. If a change in dosage/directions has been made, ensure the prescriber has sent an updated prescription to the pharmacy.
• Encourage patients to utilize adherence programs offered at their pharmacy such as auto refill programs, med sync, or dose packing. Assist patients in enrolling in these programs by collaborating with their pharmacy as needed.
• Encourage patients to call the Member Services number on the back of their Capital Blue Cross ID card with any questions regarding their pharmacy benefit.
• Minimize the use of manufacturer samples, except to those patients who are new to therapy, before they have their first fill. CMS will begin tracking adherence beginning with the first fill date.
• If patients wish to use the Veteran’s Administration for medications, ask them to consistently use the VA rather than switching back and forth with a traditional pharmacy. Claims through the VA are not captured by CMS.