Medicare Formulary Strategy Lead

Job Description Join us as a Medicare Formulary Strategy Lead, where you will play a vital role in shaping and executing our formulary strategies for Medicare, including MAPD (HMO, PPO, DSNP), PDP, and EGWP. This position involves collaborating closely with key partners such as Medicare Pharmacy Operations, UM Operations, Compliance, STARS, Medical Management, Actuarial, Product, Clinical, and Finance teams to ensure our formularies are clinically sound, cost-effective, competitive, and adhere to CMS regulations. How You Will Make an Impact: Formulary Development & Strategy Lead the annual planning process for Medicare formularies from initiation through CMS submission and final approval. Develop and implement strategies for Medicare formularies that emphasize clinical effectiveness, cost efficiency, compliance, and market competitiveness. Conduct in-depth competitive analyses, assess rebate and cost-saving opportunities, evaluate customer cohort profitability, and create product-specific strategies to meet changing market demands. Support the customized development of formularies tailored to the specific needs of each Medicare product. Research market trends, analyze competitive positioning, and navigate the regulatory landscape to inform formulary strategies. Governance & Review Engage in the Pharmacy & Therapeutics (P&T) and Business Assessment Committee to ensure decisions are evidence-based and compliant with CMS standards. Collaborate closely with Actuarial, Finance, Clinical, and Product teams to model financial scenarios, assess impacts on members, and evaluate competitive positioning. Execute ongoing and ad hoc reviews focusing on specialty tiers, utilization management, STARS performance, and management of high-cost/high-trend drugs. Guarantee compliance with CMS regulatory standards for P&T. Work with Pharmacy Benefit Managers (PBM) and internal partners to secure CMS approval of formularies. Market Monitoring & Trends Monitor evolving drug trends, competitive dynamics, and usage patterns to proactively identify opportunities and risks. Collaborate with Actuarial and Data & Analytics teams to analyze formulary performance including profitability, trend tracking, utilization management performance, and tier exception reviews. Refine strategies based on market intelligence and performance insights. What You Bring: Bachelor's degree or advanced degree (as applicable). A minimum of 8 years of experience in a related field. In lieu of a degree, 10+ years of experience in a relevant field is acceptable. Current valid unrestricted state(s) RPH license required. Bonus Points (preferred qualifications): At least 5 years of experience in Medicare managed care pharmacy; combinations of education and experience that provide an equivalent background are also acceptable. Advanced degree preferred (PharmD, MBA, MPH, or equivalent). A minimum of 5 years of experience specifically in Medicare Part D & B formulary management with either a Medicare plan sponsor or pharmacy benefit manager (PBM). Strong comprehension of Medicare Part D & B formulary requirements and regulatory guidelines. Thorough understanding of Medicare regulatory obligations for Pharmacy and Therapeutics Committees. Strong analytical skills, data interpretation proficiency, and understanding of trend management. Knowledge related to Part D Stars measures and their relevance to formulary strategy. Exceptional communication and presentation abilities, capable of engaging with leadership and cross-functional stakeholders. Experience in strategic planning and execution within the Medicare domain. Adept at synthesizing clinical, financial, and regulatory insights into actionable strategies. Robust analytical and problem-solving capabilities. Proven project management expertise, including the development of timelines, prioritization, and coordination across functions. This position allows for remote work but is ideally suited for those situated in the Raleigh-Durham, NC area. What You'll Gain: An opportunity to be at the forefront of health care delivery within a community-focused team. Work-life balance, flexibility, and the independence to excel in your role. Comprehensive medical, dental, and vision coverage alongside various health and wellness programs. Support for parental leave, adoption, and surrogacy assistance. Opportunities for career development and tuition reimbursement for ongoing education. 401k with employer match, including an annual company contribution. Salary Range: At Blue Cross NC, we are committed to offering a fair and equitable compensation package, generally starting near the midpoint of the range provided. Salary decisions take into account factors such as experience, training, specialized skills, licensure, and business needs. Our base salary is part of a comprehensive Total Rewards package that includes an Annual Incentive Bonus based on company goals and individual performance, 401(k) with employer match, generous Paid Time Off (PTO), and competitive health benefits and wellness programs. Based on annual corporate goal achievement and individual performance. Salary Range: $130,560.00 - $208,896.00 Important Notice: We’ve become aware of scams involving individuals or organizations posing as Blue Cross and Blue Shield of North Carolina, requesting financial information under pretense of recruitment activities. Our hiring process does not involve text-based conversations or interviews and does not require any payment or fees from applicants. All legitimate career opportunities are posted on the official Blue Cross NC careers website. If you suspect fraudulent activity or have provided personal information under misleading circumstances, please report it to local authorities. Any fraudulent activities should be reported to the HR department.

Created: 2026-03-06