Director of Pharmacy Benefit Manager Oversight

About the Organization:

The Division of Insurance ("DOI"), an Agency within the Office of Consumer Affairs and Business Regulation, administers the Commonwealth’s insurance consumer protection laws through its regulation of the insurance industry. The primary mission of the Division is to monitor the solvency of its licensees in order to promote a healthy, responsive and willing marketplace for consumers who purchase insurance products. The Division also investigates and responds to consumer inquiries and complaints, enforces state insurance laws and regulations, and provides the public with accurate and unbiased insurance information. An important aspect of the Division’s work is ensuring that the individuals and business entities conducting the business of insurance in Massachusetts do so in a legal and timely manner.

The Division of Insurance is committed to creating and sustaining a work culture that is welcoming, inclusive, and mutually respectful to all its employees regardless of race, color, age, creed, religion, national origin, ethnicity, sex, gender identity or expression, sexual orientation, genetic information, veteran or disability status. We strive to reflect diversity in all facets and levels of our agency. The Division of Insurance values inclusiveness and diversity within their employee and management teams. Within our community we strive to create and maintain working and learning environments that are inclusive, equitable, and welcoming.

The Division of Insurance is committed to ensuring a diverse and inclusive workplace where all employees feel respected, valued, and empowered to maximize their skills and talents to serve our citizens. 

About the Role:

The Director of Pharmacy Benefit Manager Oversight operating within the Health Care Access Bureau is authorized, pursuant to M.G.L. c. 176Y, to oversee the practices of licensed Pharmacy Benefit Managers, including their operations with insured health plans that either provide or arrange for the delivery of health care services through networks of providers, or that employ utilization review systems to evaluate the medical necessity and appropriateness of requested health care services. The primary purpose of the Director of Pharmacy Benefit Manager Oversight is to assist the Commissioner of Insurance and Deputy Commissioner of the Health Care Access Bureau, in the coordination of pharmacy benefit reviews, which comprises but is not limited to the following duties:

• Oversee the review of Pharmacy Benefit Managers applications for licensure. Review is of carriers’ operations, including utilization review, quality assurance, contracts with pharmacies and prescription drug manufacturers, and of their disclosure practices in relation to regulatory standards and statutory requirements.
• Manage the review of pharmacy benefit manager consumer communications, including explanations of benefits given to consumers, employers or health care providers.
• Collaborate with staff from the Health Policy Commission to oversee the collection of information related to Pharmacy Benefit Managers and the processing of insured health plans’ pharmacy benefit denials and appeals as overseen by OPP.
• Participate in meetings with other state personnel, including parties representing the Governor’s Office; Executive Office of Economic Development agencies, Executive Office of Health and Human Service agencies, and Executive Office for Administration and Finance agencies; the Attorney General’s Office; the Center for Health Information and Analysis, the Health Policy Commission and the state legislature regarding health care delivery systems.
• Call meetings with external stakeholders to explore pharmacy benefit policy issues and develop regulatory guidance where appropriate.
• Provide technical assistance in the development of regulatory guidance applicable to pharmacy benefits.
• Provide technical assistance in market conduct reviews of individual Pharmacy Benefit Manager practices.
• Monitor market trends in pharmaceutical benefits in collaboration with staff from the Health Care Access Bureau and Bureau of Managed Care