Clinical Practice Guidelines
ADHD:
Approved September 2026
Clinical Practice Guideline for the Diagnosis, Evaluation and Treatment of Attention-Deficit Disorder in Children and Adolescents in the Primary Care Setting
Follow-Up Care for Children Prescribed ADHD Medication (ADD-E) HEDIS®
The percentage of persons newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up visits within a 300-day (10-month) period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported:
- Initiation Phase: The percentage of persons 6–12 years of age with a prescription dispensed for ADHD medication, who had one follow-up visit with a practitioner with prescribing authority during the 30-day initiation phase.
- Continuation and Maintenance Phase: The percentage of persons 6–12 years of age with a prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the initiation phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.
Nationally Recognized Source
American Academy of Pediatrics
Anxiety:
Approved September 2026
Treatment of Adults (18 years and older) with General Anxiety Disorder (GAD) in the Primary Care Setting
Nationally Recognized Source
American Academy of Family Physicians
Anxiety:
Approved September 2026
Treatment of Children and Adolescents with Anxiety Disorders
Nationally Recognized Sources
American Academy of Child & Adolescent Psychiatry
American Academy of Family Physicians
Depression:
Approved September 2026
Managing Adults with Depression in the Primary Care Setting
Depression Screening and Follow-up for Adolescents and Adults (DSF-E) HEDIS®
The percentage of persons 12 years of age and older who were screened for clinical depression using a standardized instrument and, if screened positive, received follow-up care.- Depression Screening. The percentage of persons who were screened for clinical depression using a standardized instrument.
- Follow-Up on Positive Screen. The percentage of persons who received follow-up care within 30 days of a positive depression screen finding.
Nationally Recognized Source
American College of Physicians
American Academy of Family Physicians
Depression Remission or Response for Adolescents and Adults (DRR-E) HEDIS®
The percentage of persons 12 years of age and older with a diagnosis of depression and an elevated PHQ-9 score, who had evidence of response or remission within 120-240 days (4-8 months) of the elevated score.- Depression Follow-Up PHQ-9. The percentage of persons who have a follow-up PHQ-9 score documented within 120-240 days (4-8 months) after the initial elevated PHQ-9 score.
- Depression Remission. The percentage of persons who achieved remission within 120-240 days (4-8 months) after the initial elevated PHQ-9 score.
- Depression Response. The percentage of persons who showed response within 120-240 days (4-8 months) after the initial elevated PHQ-9 score.
Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E) HEDIS®
The percentage of persons 12 years of age and older with a diagnosis of major depression or dysthymia, who had an outpatient encounter with a PHQ-9 score present in their records in the same assessment period as the encounter.
Nationally Recognized Source
American College of Physicians
American Academy of Family Physicians
Depression:
Approved September 2026
Managing Depression in Children and Adolescents less than 18 years old in Primary Care Setting
Depression Screening and Follow-Up for Adolescents and Adults (DSF-E) HEDIS®
The percentage of persons 12 years of age and older who were screened for clinical depression using a standardize instrument and, if screened positive, received follow-up care.
- Depression Screening. The percentage of persons who were screened for clinical depression using a standardized instrument.
- Follow-Up on Positive Screen. The percentage of persons who received follow-up care within 30 days of a positive depression screen finding.
Depression Remission or Response for Adolescent and Adults (DRR-E) HEDIS®
The percentage of persons 12 years of age and older with a diagnosis of depression and an elevated PHQ-9 score, who had evidence of response or remission 120-240 days (4-8 months) of the elevated score.
- Depression Follow-up PHQ-9. The percentage of persons who have a follow-up PHQ-0 score documented within 120-240 days (4-8 months) after the initial elevated PHQ-0 score.
- Depression remission. The percentage of persons who achieved remission within 120-240 days (4-8 months) after the initial elevated PHQ-9 score.
- Depression response. The percentage of persons who showed response within 120-240 days (4-8 months) after the initial elevated PHQ-9 score.
Utilization of the PHQ-9 to Monitor Depression Symptoms for Adolescents and Adults (DMS-E) HEDIS®
The percentage of persons 12 years of age and older with a diagnosis of major depression or dysthymia, who had an outpatient encounter with a PHQ-9 score present in their records in the same assessment period as the encounter.
Nationally Recognized Source
American Academy of Pediatrics
Opioid Use:
Approved September 2026
Use of Opioids at High Dosage (HDO) HEDIS®
The percentage of persons 18 years of age and older who received prescription opioids at a high dosage (average morphine milligram equivalent dose (MME) ≥ 90) for ≥ 15 days during the measurement period.
Use of Opioids from Multiple Providers (UOP) HEDIS®
The percentage of persons 18 years of age and older, receiving prescription opioids for ≥15 days during the measurement year, who received opioids from multiple providers. Three rates are reported:
- Multiple prescribers: The percentage of persons receiving prescriptions for opioids from >4 different prescribers during the measurement period.
- Multiple pharmacies: The percentage of persons receiving prescriptions for opioids from >4 different pharmacies during the measurement period.
- Multiple prescribers and multiple pharmacies: The percentage of members receiving prescriptions for opioids from >4 different prescribers and >4 different pharmacies during the measurement period (i.e., the percentage of persons who are numerator compliant for both the Multiple Prescribers and Multiple Pharmacies rates).
Risk of Continued Opioid Use (COU) HEDIS®
The percentage of persons 18 years of age and older who have a new episode of opioid use that puts them at risk for continued opioid use. Two rates are reported:
- The percentage of persons with at least 15 days of prescription opioids in a 30-day period.
- The percentage of persons with at least 31 days of prescription opioids in a 62-day period.
Nationally Recognized Sources
Centers for Disease Control and Prevention
Pennsylvania Department of Health
U.S. Department of Health and Human Services
American Society of Addiction Medicine
Substance Abuse:
Approved September 2026
Treatment of Adults (18 years old and older) with Substance Abuse Disorders in the Primary Care Setting
Initiation and Engagement of Alcohol and Other Drug Abuse or Dependence Treatment (IET) HEDIS®
The percentage of new substance use disorder (SUD) episodes that result in treatment initiation and engagement. Two rates are reported:
- Initiation of SUD treatment. The percentage of new SUD episodes that result in treatment initiation through an inpatient SUD admission, outpatient visit, intensive outpatient encounter, partial hospitalization, telehealth or medication treatment within 14 days.
- Engagement of SUD treatment. The percentage of new SUD episodes that have evidence of treatment engagement within 34 days of initiation.
Nationally Recognized Sources
National Institute on Drug Abuse
American Academy of Family Physicians
American Psychiatric Association
Substance Abuse and Mental Health Services Administration
American Journal of Managed Care
Adult Cholesterol Management:
Approved September 2026
Statin Therapy for Patients with Cardiovascular Disease (SPC-E) HEDIS®
The percentage of persons 21-75 years of age during the measurement period who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria. Two rates are reported:
- Received Statin Therapy. Persons who were dispensed at least one high-intensity or moderate-intensity statin medication during the measurement period.
- Statin Adherence 80%. Persons who remained on a high-intensity or moderate-intensity statin medication for at least 80% of the treatment period.
Nationally Recognized Sources
American College of Cardiology
American College of Cardiology
American Heart Association
American Academy of Family Physicians (AAFP)
Statin Therapy for Patients with Diabetes (SPD-E) HEDIS®
The percentage of persons 40-75 years of age during the measurement year with diabetes who do not have clinical atherosclerotic cardiovascular disease (ASCVD) who met the following criteria.
Two rates are reported:
- 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.
Adult Diabetes:
Approved September 2026
Adult Diabetes Management
Glycemic Status Assessment for Patients with Diabetes (GSD) HEDIS®
The percentage of persons 18-75 years of age with diabetes (types 1 or 2) whose most recent glycemic status (hemoglobin A1c [HbA1c] or glucose management indicator [GMI]) was at the following levels during the measurement period:
- Glycemic status <8.0%
- Glycemic status >9.0%
Blood Pressure Control for Patients with Diabetes (BPD) HEDIS®
The percentage of persons18-75 years of age with diabetes (types 1 or 2) whose blood pressure was adequately controlled (<140/90 mm Hg) during the measurement period.
Eye Exam for Patients with Diabetes (EED) HEDIS®
The percentage of persons 18-75 years of age with diabetes (types 1 or 2) who had a retinal eye exam.
Kidney Health Evaluation for Patients with Diabetes (KED) HEDIS®
The percentage of persons 18-85 years of age with diabetes (type 1 or type 2) who received a kidney health evaluation, defined by an estimated glomerular filtration rate (eGFR) and a urine albumin-creatine ratio (uACR), during the measurement period.
Nationally Recognized Sources
American Diabetes Association
Asthma:
Approved September 2026
Management of all members with asthma
Follow-Up After Acute and Urgent Care Visits for Asthma (AAF-E) HEDIS®
The percentage of persons 5-64 years of age with an urgent care visit, acute inpatient discharge, observation stay discharge or ED visit with a diagnosis of asthma that hat a corresponding outpatient follow-up visit with a diagnosis of asthma within 30 days.
Nationally Recognized Source
American Academy of Family Physicians (AAFP)
Global Strategy for Asthma Management and Prevention
Cardiovascular Risk Factors and Coronary Artery Disease:
Approved September 2026
Recommendations for all adult members without known Coronary Heart Disease (CHD) whose symptoms suggest chronic stable angina, members with known stable angina, asymptomatic members with evidence suggesting CHD on previous testing or with risk factors that predispose them to CHD and those who have had a past MI or coronary artery revascularization procedure
Statin Therapy for Patients with Cardiovascular Disease (SPC-E) HEDIS®
The percentage of persons 21-75 years of age during the measurement period who were identified as having clinical atherosclerotic cardiovascular disease (ASCVD) and met the following criteria.
Two rates are reported:
- Received Statin Therapy: Members who were dispensed at least one high-intensity or moderate-intensity statin medication during the measurement year.
- Statin Adherence 80%: Stating Adherence 80%: Members who remained on a high-intensity or moderate-intensity statin medication for at least 80% of the treatment period.
Nationally Recognized Sources
American Heart Association
American College of Cardiology
Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) HEDIS®
The percentage of persons 18 years of age and older during the measurement period who were hospitalized and discharged from July 1 of the year prior to the measurement period to June 30 of the measurement period with a diagnosis AMI who received persistent beta-blocker treatment for 180 days (6 months) after discharge.
Cardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia (SMC) HEDIS®
The percentage of persons 18-64 years of age with schizophrenia or schizoaffective disorder and cardiovascular disease, who had an LDL-C test during the measurement period.
Nationally Recognized Sources
American Heart Association
American College of Cardiology
COPD:
Approved September 2026
Management of adult members with stable COPD and acute exacerbations of COPD
Pharmacotherapy Management of COPD Exacerbation (PCE) HEDIS®
The percentage of COPD exacerbations for persons 40 years of age and older who had an acute inpatient discharge or ED visit on or between Jan. 1 and Nov. 30 of the measurement period 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.
Nationally Recognized Sources
The Global Initiative for Chronic Obstructive Lung Disease (GOLD)
American Academy of Family Physicians (AAFP)
Heart Failure Guidelines:
Approved September 2026
Persistence of Beta-Blocker Treatment After a Heart Attack (PBH) HEDIS®
The percentage of persons 18 years of age and older during the measurement year who were hospitalized and discharged 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 180 days (six months) after discharge.
Controlling High Blood Pressure (CBP) HEDIS®
The percentage of persons 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during the measurement period.
Nationally Recognized Sources
American Heart Association
American College of Cardiology
Heart Failure Society of America
Hypertension Management:
Approved September 2026
Management of all members ages 18-85 with hypertension
Controlling High Blood Pressure (CBP) HEDIS®
The percentage of persons 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90 mmHg) during the measurement period.
Nationally Recognized Sources
American College of Cardiology
Lung Cancer Screening:
Approved September 2026
Tobacco Use Screening and Cessation Intervention (TSC-E)
The percentage of persons 12 years of age and older who were screened for commercial tobacco product use at least once during the measurement period, and who received tobacco cessation intervention if identified as a tobacco user.
Two rates are reported:
- Tobacco Use Screening: The percentage of persons who were screened for tobacco use.
- Cessation Intervention: The percentage of persons who were identified as a tobacco user and who received tobacco cessation intervention.
Nationally Recognized Sources
United States Preventive Service Task Force
National Cancer Institute
American College of Radiology
Adult Preventive Guidelines:
Approved September 2026
Adults' Access to Preventive/Ambulatory Health Services (AAP) HEDIS®
The percentage of persons 20 years of age and older who had an ambulatory or preventive care visit. The organization reports three separate percentages for each product line:
- Persons enrolled in Medicaid and Medicare members who had an ambulatory or preventive care visit during the measurement period.
- Persons enrolled in a commercial product who had an ambulatory or preventive care visit during the measurement period or the 2 years prior to the measurement year.
Nationally Recognized Source
United States Preventative Service Task Force
American Academy of Family Physicians
Prenatal Clinical Practice Guidelines:
Approved September 2026
Care provided throughout the course of an entire pregnancy with the goal of preventing and/or minimizing complications as well as decreasing the incidence of maternal and perinatal mortality
Prenatal and Postpartum Care (PPC) HEDIS®
The percentage of deliveries of live births on or between Oct. 8 of the year prior to the measurement period and Oct. 7 of the measurement period. For these members, the measure assesses the following facets of prenatal and postpartum care:
- Timeliness of Prenatal Care: The percentage of deliveries that received a prenatal care visit in the first trimester on or before the enrollment start date or within 42 days of enrollment in the organization
- Postpartum Care: The percentage of deliveries that had a postpartum visit on or between 7 and 84 days after delivery
Nationally Recognized Sources
United States Preventative Service Task Force
American Congress of Obstetricians and Gynecologists
Pediatric Preventive Guidelines:
Approved September 2026
Well-Child Visits in the First 30 Months of Life (W30) HEDIS®
The percentage of persons who had the following number of well-child visits with a PCP during the last 15 months. The following rates are reported:
- Well-Child Visits in the First 15 Months. Persons who turned 15 months old during the measurement year: Six or more well-child visits
- Well-Child Visits for Age 15 Months–30 Months. Persons who turned 30 months old during the measurement year: Two or more well-child visits
Child and Adolescent Well-Care Visits (WCV) HEDIS®
The percentage of members 3–21 years of age who had at least one comprehensive well-care visit with a PCP or an OB/GYN practitioner during the measurement year.
Nationally Recognized Sources
American Academy of Pediatrics
**Additional Resources for UPMC Health Plan Members
- UPMC MyHealth 24/7 Nurse Line is staffed by experienced registered nurses and is available 24/7 to provide telephone support to members. Call 1-866-918-1591. TTY users should call 711.
- Health coach Programs provide intensive case management for members with specific chronic illnesses or conditions. The programs are built upon best practices and accepted clinical guidelines and include:
- Diabetes
- Respiratory
- Asthma
- COPD
- Behavioral health
- Depression
- Cardiovascular
- Heart failure
- Coronary artery disease
- Hypertension
- Hyperlipidemia
*Members and providers can get additional health coaching program information by calling 1-866-778-6073.
**UPMC Prescription for Wellness (PFW) is a platform that affords providers the opportunity to refer their patients who are UPMC Health Plan members to payer-sponsored clinical and wellness services. PFW is integrated into EMRs, offers multi-channel outreach, and enables providers and UPMC Health Plan to efficiently collaborate on supporting the health of the patient-member population they both serve. PFW dramatically improves patient-member engagement, demonstrating that payer-sponsored clinical and wellness services offer a viable set of options to improve health when prescribed by a healthcare provider
***HEDIS® The Healthcare Effectiveness Data and Information Set (HEDIS®) is a registered trademark of NCQA.
Learn More About Prescription for Wellness
Health Management Programs
- Physical health conditions
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- COPD
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- A-fib
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- Anxiety
- Depression
- Substance use
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For additional information:
- Providers can call 1-855-772-8762 or email healthplansparef@upmc.edu.
- Members can call 1-866-778-6073.
Online interactive preventive health programs and resources are available in partnership with WebMD at www.upmchealthplan.com.
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