PRN Pharmacist Reviewer - Medicare Part D Formulary Criteria Review

Rainmakers Strategic Solutions is seeking PRN pharmacists to support our contract with the Centers for Medicare & Medicaid Services (CMS) reviewing the prior authorization (PA) and step therapy (ST) criteria that Medicare Part D plan sponsors submit for approval. Pharmacist Reviewers evaluate sponsor criteria against CMS guidance in Chapter 6 of the Medicare Prescription Drug Benefit Manual, FDA-approved labeling, recognized Part D compendia, and widely accepted treatment guidelines;

determine whether each criteria element is approvable; and write clear, specific comments explaining any deficiencies.

This is not a patient-level prior authorization role. Reviewers assess plan-level criteria across many plans and formularies. The position requires strong knowledge of Medicare Part D requirements and utilization management principles, sound clinical judgment, and the discipline to deliver accurate, consistent reviews within fixed CMS deadlines.

• Reviews sponsor-submitted PA and ST criteria for compliance with Chapter 6 of the Medicare Prescription Drug Benefit Manual and related CMS guidance, during both the annual review (conducted in three phases) and monthly reviews of new and updated criteria.
• Evaluates each PA criteria field, including indication indicator, off-label uses, exclusion criteria, required medical information, age and prescriber restrictions, coverage duration, other criteria, and prerequisite therapy, for consistency with FDA-approved labeling, recognized Part D compendia, and widely accepted treatment guidelines.
• Evaluates ST criteria to determine whether prerequisite drugs are clinically appropriate, account for all indications of the stepped drug, follow on-label versus off-label standards, and are not overly burdensome in the number of prerequisite drugs or the required duration of prerequisite therapy.
• Applies CMS review principles for Part B versus Part D step therapy, indication-based formulary design, over-the-counter step therapy prerequisites, and synchronization of criteria with the submitted formulary file.
• Supports review of utilization management for Medicare drugs selected for negotiation under the Inflation Reduction Act, identifying where sponsors apply more restrictive PA or ST to a selected drug than to formulary alternatives in the same class, and evaluating sponsor justifications.
• Writes clear, specific, and consistent comments to plan sponsors for each failed criteria element, using standard language for the same review concern and identifying every issue so the sponsor can correct the criteria without guessing the intent.
• Reviews resubmitted criteria, formulary files, and clinical justifications to determine whether revisions resolve the concerns previously communicated to the sponsor.
• Applies the same pass/fail decision and comment to identical criteria across all formularies, using criteria identification codes and established decision precedents.
• Uses drug information resources including Micromedex Drug Dex, AHFS Drug Information, NCCN Clinical Practice Guidelines, Clinical Pharmacology, and Lexi-Drugs to evaluate the clinical basis of submitted criteria.
• Interprets and applies federal Medicare Part D statutes, regulations, and CMS guidance related to formulary and utilization management review.
• Maintains current knowledge of CMS Part D policy, new drug approvals and indications, drug safety updates such as new boxed warnings, and changes in treatment guidelines.

• Doctor of Pharmacy degree from an accredited college or university
• Current, active, unrestricted license to practice pharmacy in the United States
• Minimum five years of experience in clinical pharmacy, formulary management, utilization management, pharmacy benefit management, or Medicare Part D
• Experience developing or reviewing PA and ST criteria for a Part D plan sponsor, pharmacy benefit manager, or Pharmacy and Therapeutics (P&T) committee strongly preferred
• Pharmacy residency or board certification preferred
• Advanced knowledge of Medicare Part D coverage requirements and utilization management programs, including Chapter 6 of the Medicare Prescription Drug Benefit Manual
• Strong understanding of FDA-approved versus medically accepted (compendia-supported) indications and how they apply to coverage criteria
• Strong clinical background with demonstrated ability to review, interpret, and apply treatment guidelines and evidence-based literature
• Proficiency in the use of Micromedex…