Clinical Pharmacist (Medicare Part D)

Job Description

Position Purpose: The Clinical Pharmacist – Medicare Part D provides specialized support for Medicare lines of business as it applies to clinical pharmacy operations for Medicare Part D. This position reviews Medicare Part D formularies and makes clinical recommendations with respect to utilization management restrictions and to ensure formularies meet the therapeutic requirements mandated by CMS.

Provides clinical and operational support for planning, creating, maintaining and reviewing Health Net Medicare Part D Formularies, Prior Authorization (PA) criteria, Step Therapy (ST) Criteria and other utilization management (UM) restrictions.

Ensures timely and accurate submission of all HPMS formulary files, PA files, ST files and other UM restrictions in accordance with CMS requirements.

Creates, maintains, reviews and approves ST files/documents for submission to HPMS.

Responsible for maintaining files to support monthly updates of formulary print and website documents including Health Net Medicare Part D formularies, PA criteria, ST criteria and Negative Formulary Changes.

Oversees Transition Program to ensure clinical and operational functionality is implemented to support an appropriate transition process for new enrollees prescribed Part D drugs that are not on the formulary.

Oversees Negative Formulary Change Process to ensure required notification and revisions of formulary documents and systems are complete.

Performs quality assurances on and maintains Health Net’s Medicare Part D formularies in the Formulary and Benefit (FAB) system.

Acts as clinical liaison between HNPS and the pharmacy claims processor.

Participates in the development and maintenance of new programs required by CMS.

Ensures HNPS’ compliance with CMS formulary requirements per the Medicare Prescription Drug Benefit Manual, Chapter 6 – Part D Drugs and Formulary Requirements

Create/revise policies and procedures pertaining to Health Net’s Medicare Part D program.

Provides guidance and clarification for Part B v. Part D coverage determinations.

Provides timely and accurate responses to regional and departmental inquiries/requests regarding Medicare Part D formulary issues.