This position will play an important role in managing Medicare Part D Formulary; evaluation and review of new drugs with the Pharmacy & Therapeutics Subcommittee/Committee. This position is accountable for ensuring regulatory compliance with respect to the Medicare Part D formulary submissions to CMS, pharmacy benefit, formulary and transition program implementation with PBM, website content for all business lines, pharmacy network and CMS’s Part D regulatory audits. The Clinical Pharmacist works in collaboration with other departments to produce pharmacy-related marketing materials in accordance with CMS guidelines. The Clinical Pharmacist stays abreast of pharmacy, PBM and payer industry changes, best practices, and CMS’s rules and regulations.
- Ensures regulatory compliance with P&T operations, Formulary & Benefit Administration, Transition Program, annual Part D bid submission process, pharmacy-related member communications and marketing materials, website content, pharmacy network and CMS’s regulatory audits as follows:
- Produces and maintains Part D Formulary, Prior Authorization criteria, Step Therapy criteria and Supplemental files in accordance with CMS requirements on monthly and annual basis and submits these files to CMS.
- Develops and maintains formulary exception criteria.
- Evaluates and reviews new drugs/biosimilars with the Pharmacy & Therapeutics Subcommittee/Committee within 90-180 days of being marketed and makes formulary and utilization management recommendations based on the clinical appropriateness, cost analysis and CMS guidelines.
- Works in collaboration with Medical Directors to evaluate and analyze treatment protocols and procedures related to the SCAN Health Plan formulary, at least annually.
- Provides CMS Part D regulatory audit support for respective areas.
- Produces member communications and marketing materials, within internally determined timeframes, with accuracy and in accordance with the CMS marketing guidelines. Partners with Marketing, Compliance and Member Services and vendors, as needed.
- Maintains on-line comprehensive formulary on monthly basis in accordance with CMS requirements.
- Reviews accuracy of the Pharmacy Benefits for the annual BID submission to CMS.
- Prepares Formulary/Pharmacy Benefits Industry Analysis annually.
- Monitors drug pipeline and the payer industry changes throughout the year to identify potentially high Part D impact drugs. Manage Part B drug trend and value based opportunities.
- Oversees PBM operations in the areas of Formulary, Opioid Safety Edits, Pharmacy Benefits, Transition Program, Prescriber Enrollment Requirements and Pharmacy Network Implementation.
- Ensures AEP readiness and assists in training of other departments.
- Develops and/or implements clinical pharmacy programs in-house or in collaboration with the PBM Company, as needed.
- Serves as the clinical subject matter expert for respective areas, providing guidance as needed.
- Maintains current knowledge of Medicare Part D regulations by participating in CMS calls and reading released guidance and implementing changes to maintain compliance.
- Manages multiple deadlines and completes projects with 100% accuracy.
- Maintains professional and technical knowledge by conducting research and by attending educational and technological workshops. This position requires contributions to team effort by accomplishing and sharing related results with other staff.
- Contributes to team effort by accomplishing related results as needed.
- Collaborates with other team members within the Pharmacy Department; collaborates with other SCAN departments: Compliance, Marketing, HCI, Product, Member Services to support the achievement of SCAN’s Vision and Goals.
- Pharm D. Degree, required.
- California Pharmacy Licensure, required within 6 months of hire.
- Residency Program in Managed Care, Pharmacy Practice, Drug Information or Geriatric Pharmacy, preferred.
- Managed care experience at a PBM, health plan, or medical group required.
- Medicare Part D experience in formulary management required.
- Excellent verbal/written communication, interpersonal, presentation, customer, problem-solving and computer skills, required.
- Effective utilization of information systems required.