TIER 2 · PHARMACY NETWORK · CONFIGURATION AUDIT
Five Network Terms Set Where Members Fill.
The Routing Pattern Rarely Matches the Clause.
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 pharmacy network design
Five terms that set where members are allowed to fill
Compare the routing pattern to the exclusion log
Where 'preferred network' becomes a funnel
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A complete audit framework you can run in half a day.
WHAT IS IN THE WORKSHEET
PASS 03
Audit the Exclusion Log
Pull where claims actually fill and compare it to the network the contract describes. A routing pattern concentrated in PBM-owned pharmacies beyond what the design requires is a steering finding.
PASS 01
Read the Five Network Terms
Five terms set your network: the preferred-pharmacy definition, the exclusion criteria, the mail-order mandate, the specialty carve-out, and the out-of-network penalty. Together they decide where members are allowed to fill.
PASS 02
Compare Pattern to Design
Pull where claims actually fill and compare it to the network the contract describes. A routing pattern concentrated in PBM-owned pharmacies beyond what the design requires is a steering finding.
ACTION PLAN
This Quarter's Action Plan
Run the three passes, document the routing-versus-design gap, and require the exclusion rationale in writing. A network you did not design is a network designed for someone else's margin.