TIER 2 · MEMBER TRANSITION · AUDIT WORKSHEET
Five Clauses Protect Members During Transitions.
Most Plan Sponsors Assume They Execute. They Don't.
A 2-page printable worksheet PBS uses across 100s of PBM contract reviews annually. Free download. Sent to your inbox.
Three audit passes on member-transition protection
Five clauses that protect members during a PBM change
Transition-event log to test the assumption
Where continuity-of-care quietly fails
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A complete audit framework you can run in half a day.
WHAT IS IN THE WORKSHEET
PASS 03
Document the Gaps
They often don't. The second pass builds a transition-event log and checks whether each protection actually fired during the last PBM change or open enrollment, or whether members fell through.
PASS 01
Read the Five Protections
Five clauses protect members through a transition: continuity-of-care, prior-auth honoring, refill-too-soon override, formulary grandfathering, and member-communication timing. Plan sponsors assume they execute automatically.
PASS 02
Test the Assumption
They often don't. The second pass builds a transition-event log and checks whether each protection actually fired during the last PBM change or open enrollment, or whether members fell through.
ACTION PLAN
This Quarter's Action Plan
Run the three passes, log the transition events, and require the PBM to report transition-protection execution. Continuity of care that lives only in the contract is not continuity of care.