TIER 2 · STEP THERAPY OVERRIDE · AUDIT WORKSHEET
Five Clauses Govern Step Therapy Overrides.
The Workflow 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 step therapy overrides
Five clauses that govern when an override must be granted
Where the operational workflow fails the contract
Member-impact log to document the gap
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A complete audit framework you can run in half a day.
WHAT IS IN THE WORKSHEET
PASS 03
Document Member Impact
The promise and the practice diverge. The second pass tests whether the override workflow actually runs in the turnaround the contract requires, or whether members abandon therapy waiting.
PASS 01
Read the Override Clauses
Five clauses govern step therapy overrides: the medical-exception standard, the turnaround requirement, the grandfathering terms, the continuity-of-care rule, and the appeal pathway. The contract promises an override process.
PASS 02
Test the Workflow
The promise and the practice diverge. The second pass tests whether the override workflow actually runs in the turnaround the contract requires, or whether members abandon therapy waiting.
ACTION PLAN
This Quarter's Action Plan
Run the three passes, document where the workflow fails the clause, and require override turnaround reporting. Step therapy that can't be overridden on time is cost control doing clinical harm.