TIER 2 · GENERIC EFFECTIVE RATE · AUDIT WORKSHEET
Five GER Terms Decide Whether Your Guarantee Applies.
The PBM Controls Four. The Worksheet Checks All Five.
A 2-page printable worksheet PBS uses across 100s of PBM contract reviews annually. Free download. Sent to your inbox.
Three audit passes on your generic effective rate guarantee
Five GER terms that decide whether the guarantee applies
Reconcile the guaranteed rate against actual performance
Where exclusions quietly shrink the guarantee
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A complete audit framework you can run in half a day.
WHAT IS IN THE WORKSHEET
PASS 03
Find the Exclusions
Pull your generic effective rate and compare the guaranteed number to actual performance. A guarantee hit on paper while your plan overpays in practice is the GER game working as designed.
PASS 01
Read the Five GER Terms
Five terms decide whether your GER guarantee means anything: the generic definition, the included-claims set, the reconciliation method, the exclusion list, and the true-up timing. The PBM controls four of them.
PASS 02
Reconcile Guaranteed vs. Actual
Pull your generic effective rate and compare the guaranteed number to actual performance. A guarantee hit on paper while your plan overpays in practice is the GER game working as designed.
ACTION PLAN
This Quarter's Action Plan
Run the three passes, reconcile guaranteed against actual, and require the exclusion list and reconciliation method in writing. A GER guarantee you cannot audit is a number, not a guarantee.