GuidedHealth® helps identify drug therapy opportunities
At Blue Cross and Blue Shield of New Mexico (BCBSNM), we understand that medication therapy can be an essential part of a member’s overall treatment plan. That’s why we use the GuidedHealth clinical rules platform to conduct periodic reviews to help to identify opportunities that can positively impact members’ medication therapy. This platform drives our Retrospective Drug Utilization Review (RDUR) program, which integrates medical and pharmacy claims data for generating evidence-based, medication-related recommendations for physicians and members.

The GuidedHealth program targets drug therapy issues in modules such as overutilization, safety, and cost. The table below lists the programs that were implemented during the fourth quarter of 2013. If your patient is identified via one or more of these categories, you may receive a letter from BCBSNM that references GuidedHealth.

We Invite Your Comments
In support of your treatment plan for our member, a drug therapy opportunity summary will be included with your letter for your consideration, along with a medication claims profile for the identified member. We hope you find this information helpful and we want to thank you in advance for taking the time to review all medication-related recommendations. If you receive a letter, we would appreciate your taking the time to fill out the enclosed feedback survey so we can continue to improve the service we provide.

Fourth Quarter 2013 Programs 


Program Examples


Identify potential misuse and/or abuse, as well as drug conflict and off-label use

  • Off-Label Use (requires medical claim)
  • Trinity
  • Stimulant Polypharmacy


Identify and recommend discontinuation of potentially unsafe medication use

  • High Dose Acetaminophen

Cost Savings

Promote the awareness of generic drug alternatives in place of non-formulary brand products.

  • Generic Opportunity
    • Proton Pump Inhibitors
    • Statins

The information mentioned here is for informational purposes only and is not a substitute for the independent medical judgment of a physician. Members should refer to their certificate of coverage for more details, including benefits, limitations and exclusions. Regardless of benefits, the final decision about any medication is between the member and their health care provider.

GuidedHealth is a registered trademark of Prime Therapeutics LLC (Prime), a pharmacy benefit management company. Blue Cross and Blue Shield of New Mexico (BCBSNM) contracts with Prime to provide pharmacy benefit management, prescription home delivery and specialty pharmacy services. BCBSNM, as well as several other independent Blue Cross and Blue Shield Plans, has an ownership interest in Prime. BCBSNM makes no endorsement, representations or warranties regarding GuidedHealth. If you have any questions about this product or services, you should contact Prime Therapeutics LLC directly.