Clinical Pharmacist, Formulary Management Regulatory

At CVS Health, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care.

As the nation’s leading health solutions company, we reach millions of Americans through our local presence, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, when and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it all with heart, each and every day.

Key Responsibilities:

Regulatory Compliance & Mental Health Parity, Department of Insurance Audits and Market Checks

• Ensure template formularies design and application of utilization management (UM) criteria align with MHPAEA and other federal/state regulations.
• Support PBM market conduct examinations, CMS audits, and internal regulatory reviews.
• Partner with Government Affairs, Legal, and Compliance teams to produce and validate data for exam requests.

Formulary Management

• Develop and maintain CVS Caremark's template formularies including drug tiering and UM application that meet or exceed regulatory requirements.
• Evaluate consistency in UM application across medical/surgical and mental health/substance use disorder drugs.
• Identify the Evidentiary Standards, Factors and Sources supporting the development and application of Non-Quantitative Treatment Limitations (NQTLs).
• Provide QA and sign-off on audit responses and corrective action plans.

Utilization Management

• Understand UM development and management, including prior authorization, step therapy, quantity limits, and formulary exceptions.
• Recognize decisions reflect clinical best practices and regulatory requirements.

Cross-Functional Collaboration

• Serve as a liaison between Formulary Management and internal/external stakeholders including CVS Audit Team, Legal, Compliance and Regulatory Affairs.
• Collaborate in a matrixed environment with colleagues across departments and levels.
• Present findings and recommendations to leadership and regulatory partners.

Required Qualifications:

• PharmD or equivalent clinical pharmacy degree.
• Active pharmacist license in good standing.
• Ability and willingness to work in a hybrid structure role requiring employees work 3 days/week in office at either our Buffalo Grove, IL or Pittsburgh, PA office locations.
• 3–5 years of experience in regulatory pharmacy, utilization management, or PBM operations.
• 3+ years of managed care experience.
• 3+ years of relevant UM or prior authorization experience.
• Strong understanding of MHPAEA, CMS regulations, and market conduct exam processes.
• Demonstrated understanding of UM interventions (prior authorization, step therapy, quantity limits, formulary exceptions).
• Proven proficiency in literature search and evidence-based medicine analysis.
• Experience with internal audits, external regulatory reviews, and market conduct examinations.
• Excellent written and oral communication skills, with the ability to distill complex concepts for leadership.
• Project and process management experience.
• Ability to understand and optimize complex workflow processes.
• Skilled in MS Office applications (Word, Excel, Access, PowerPoint).

Preferred Skills:

• Experience supporting audits and regulatory reviews in a PBM or managed care setting.
• Familiarity with mental health and substance use disorder treatment guidelines.
• Ability to manage complex projects and cross-functional initiatives.
• Acumen specific to Specialty Pharmacy, Utilization Management, Formulary Management.
• Knowledge of Regulatory Rules and Requirements.

Education:

• BS in Pharmacy or PharmD required

Anticipated Weekly Hours

40

Time Type

Full time

Pay Range

The typical pay range for this role is:

$118,000.00 - $206,250.00

This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls.  The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.  This position is eligible for a CVS Health bonus, commission or short-term incentive program in addition to the base pay range listed above. 
 

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