Medicare Formulary Strategy Manager

Anticipated End Date:

2025-10-29

Position Title:

Medicare Formulary Strategy Manager

Job Description:

Medicare Formulary Strategy Manager

Hybrid 1: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. Alternate locations may be considered.

• Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

A proud member of the Elevance Health family of companies, CarelonRx (formerly IngenioRx) leverages the power of new technologies and a strong, clinical-first lens, to deliver member-centered, lasting pharmacy care.

The Medicare Formulary Strategy Manager will lead the design, development, and execution of formulary strategies for all Group Retiree Solutions (GRS) formularies. This role requires close collaboration with cross-functional partners—including Clinical Pharmacy, Compliance, STARS, Medical Management, Actuary, Product, and Rebate teams—to ensure formularies are clinically appropriate, cost-effective, competitive in the marketplace, and compliant with CMS regulations. The position also provides formulary strategy support across Elevance Health’s Medicare Advantage Prescription Drug (MAPD) business.

How you will make an impact:

Formulary Development & Strategy

• Lead the annual formulary planning process from kick-off through CMS submission and final approval.

• Develop and execute formulary strategies that balance clinical efficacy, cost-effectiveness, compliance, and competitive positioning.

• Conduct competitive analyses, rebate optimization initiatives, and strategic updates aligned with evolving product and market needs.

• Support the development of tailored formularies for each Medicare product offering.

Group Retiree Solutions (GRS) Clinical Support

• Provide formulary strategy and clinical support for GRS programs.

• Support GRS product teams, and other internal business partners.

• Research market trends, evaluate competitive positioning, and assess the regulatory landscape to guide GRS clinical program strategies.

Governance & Review

• Oversee the Pharmacy & Therapeutics (P&T) and Value Assessment Committee (VAC) processes, ensuring evidence-based decision-making and CMS charter compliance.

• Partner with Actuarial teams to model financial scenarios, assess member impact, and evaluate competitive positioning.

• Conduct ongoing and ad hoc reviews focused on specialty tiers, utilization management, STARS performance, and high-cost/high-trend drugs.

Market Monitoring & Trends

• Monitor emerging drug trends, competitive market dynamics, and utilization patterns to proactively identify opportunities or risks.

• Lead monthly and quarterly analyses of formulary performance, including GLP-1 trend tracking, UM edit evaluations, and tier exception reviews.

• Refine strategy based on real-time market intelligence and performance insights.

Minimum Requirements:

• Requires BA/BS in Pharmacy and a minimum of 2 years of managed care pharmacy experience; or any combination of education and experience, which would provide an equivalent background.

• Current valid active unrestricted state(s) RPH license required.

Preferred Skills, Capabilities and Experiences:

• Advance degree preferred (PharmD, MBA, MPH, or equivalent).

• Minimum of 2 years of experience in pharmacy benefit management (PBM), Medicare Part D, or formulary management.

• Strong understanding of CMS Part D formulary requirements and regulatory guidance.

• Strong analytical, data interpretation, and trend management skills.

• Knowledge of STARS measures and their application in formulary strategy.

• Excellent communication and presentation skills, with the ability to engage leadership and cross-functional stakeholders.

• Strategic planning and execution within a regulated healthcare environment.

• Ability to synthesize clinical, financial, and regulatory insights into actionable strategies.

• Strong analytical and problem-solving abilities.