No products in the cart.
Certified Pharmacy Benefits Pharmacist (CPBP)
Official Examination Content Outline
This document provides the official content outline for the Certified Pharmacy Benefits Pharmacist (CPBP) examination. This gold-standard blueprint certifies that a professional possesses the advanced, performance-based competencies required to design, manage, and evaluate pharmacy benefit programs, ensuring cost-effective, high-quality, and compliant pharmaceutical care for covered populations.
Examination Specifications
| Name of Credential | Certified Pharmacy Benefits Pharmacist (CPBP) |
|---|---|
| Certification-Issuing Body | The Council on Pharmacy Standards (CPS) |
| Designation Awarded | CPBP |
| Target Population | Pharmacists specializing in managed care, PBMs, health plans, and consulting. |
| Examination Length | 120 multiple-choice items |
| Administration Time | 3.0 hours |
Examination Content Outline
The CPBP examination is weighted according to the five domains listed below, covering the essential competencies of managed care pharmacy, from clinical formulary management and financial oversight to regulatory compliance and network operations.
| Domain 1: Formulary and Utilization Management | 25% |
| Domain 2: PBM Operations and Network Management | 20% |
| Domain 3: Financial Management and Rebate Contracting | 25% |
| Domain 4: Quality, Clinical Programs, and Member Relations | 15% |
| Domain 5: Regulatory, Compliance, and Audit Oversight | 15% |
Domain 1: Formulary and Utilization Management (25%)
Task 1: Manage the Pharmacy & Therapeutics (P&T) committee process.
- Prepare and present clinical and economic monographs for drug formulary review.
- Critically evaluate drug pipelines and their potential impact on the formulary.
- Develop agenda items and supporting materials for P&T committee meetings.
- Implement P&T committee decisions regarding formulary placement and utilization management criteria.
- Ensure the P&T committee process is compliant with accreditation and regulatory standards (e.g., CMS).
Task 2: Design and maintain the drug formulary.
- Design a formulary based on clinical efficacy, safety, and net cost, incorporating value-based (VBID) principles.
- Develop and manage a preferred drug list, including strategies for biosimilar adoption.
- Implement formulary tiers and associated member cost-sharing structures.
- Manage the process for adding new drugs and removing obsolete drugs from the formulary.
- Assess the role of pharmacogenomics and precision medicine in formulary and benefit design.
Task 3: Develop and manage prior authorization (PA) criteria.
- Develop evidence-based clinical criteria for medications requiring prior authorization.
- Translate clinical guidelines and FDA-approved labeling into clear, objective PA criteria.
- Ensure PA criteria are designed to promote safe, effective, and cost-conscious prescribing.
- Manage the process for reviewing and approving or denying PA requests.
- Periodically review and update all PA criteria to reflect new evidence and products.
Task 4: Develop and manage step-therapy protocols.
- Design clinically sound step-therapy protocols that require the use of first-line agents before second-line agents.
- Identify appropriate first-line therapies based on evidence of efficacy, safety, and cost.
- Develop a clear process for members and providers to request an exception to a step-therapy protocol.
- Ensure that step-therapy protocols do not create undue barriers to medically necessary care.
- Stay current with state and federal legislation that may regulate the use of step therapy.
Task 5: Develop and manage quantity limit (QL) policies.
- Establish QL programs based on FDA-approved labeling, safety data, and typical dosing regimens.
- Design QLs to prevent overuse, hoarding, and reduce the risk of adverse events.
- Develop a process for reviewing requests for quantity limit overrides based on medical necessity.
- Differentiate between QLs based on dose limits versus duration limits.
- Periodically review and update QLs to align with current clinical practice.
Task 6: Manage the formulary exception and appeals process.
- Develop a clear and compliant process for members to request an exception for a non-formulary drug.
- Review formulary exception requests for medical necessity against established criteria.
- Understand the multi-level appeals process for denied exception requests, including internal and external review.
- Ensure that all decisions and appeals are processed within the timeframes mandated by CMS and other regulators.
- Analyze appeals data to identify issues with formulary design or PA criteria.
Domain 2: PBM Operations and Network Management (20%)
Task 1: Oversee pharmacy claims adjudication.
- Understand the flow of a pharmacy claim from submission to final payment.
- Interpret NCPDP standards and transaction formats used in claims processing.
- Troubleshoot and resolve common claim rejection codes.
- Ensure that utilization management edits (PA, ST, QL) are applied correctly at the point of sale.
- Manage the process for claims reversal and resubmission.
Task 2: Manage the pharmacy network.
- Design a pharmacy network that provides adequate member access while managing costs.
- Differentiate between broad, narrow, and preferred pharmacy networks.
- Oversee the pharmacy credentialing and re-credentialing process.
- Analyze the terms of a pharmacy provider contract, including reimbursement rates and performance requirements.
- Understand different reimbursement models for network pharmacies (e.g., MAC, AWP-based).
Task 3: Oversee mail order and specialty pharmacy operations.
- Evaluate the clinical and financial case for using a mandatory or voluntary mail order pharmacy.
- Manage the relationship and performance of a contracted mail order or specialty pharmacy vendor.
- Ensure that specialty pharmacies are providing required high-touch clinical services.
- Manage the distribution of limited distribution drugs (LDDs) through the specialty pharmacy network.
- Oversee credentialing and compliance for the specialty pharmacy network, including policies on white/brown bagging.
Task 4: Manage pharmacy network audits and performance.
- Design and manage a pharmacy audit program to ensure compliance with contract terms and prevent FWA.
- Analyze audit findings and manage the process for financial recoveries.
- Evaluate the structure and impact of Direct and Indirect Remuneration (DIR) fees.
- Design and manage provider performance-based reimbursement models aligned with quality metrics (e.g., Star Ratings, outcomes-based pay).
- Oversee compliance of 340B contract pharmacy arrangements within the network.
Task 5: Oversee member and provider services.
- Ensure that customer service representatives are properly trained on the pharmacy benefit.
- Develop and maintain scripts and job aids for pharmacy-related inquiries.
- Oversee the pharmacy help desk that supports providers and pharmacy staff.
- Analyze call center data to identify common member and provider issues.
- Develop and maintain the pharmacy benefit section of the member and provider portals.
Task 6: Manage Pharmacy Benefit Manager (PBM) vendor performance.
- Participate in the PBM request for proposal (RFP) and vendor selection process.
- Understand the key terms and service level agreements (SLAs) within a PBM contract.
- Conduct regular oversight meetings to monitor PBM performance against contractual guarantees.
- Validate PBM reporting on clinical, financial, and operational performance.
- Manage the implementation process when transitioning to a new PBM.
Domain 3: Financial Management and Rebate Contracting (25%)
Task 1: Analyze and manage pharmacy drug trend.
- Define and calculate the components of drug trend: utilization, unit cost, and mix.
- Analyze claims data to identify the key drug classes and products driving overall trend.
- Develop forecasts for future drug spend based on historical trends and pipeline analysis.
- Differentiate between gross drug spend and net drug spend after rebates.
- Prepare and present regular drug trend reports to leadership and clients.
Task 2: Evaluate the drug pipeline and forecast budget impact.
- Monitor the pipeline of new drugs and biologics awaiting FDA approval.
- Assess the potential clinical and financial impact of new high-cost or high-volume drugs.
- Develop budget impact models (BIMs) to forecast the cost of new drugs to the plan.
- Identify upcoming patent expirations and forecast the savings from new generics and biosimilars.
- Develop proactive management strategies for significant pipeline drugs before they launch.
Task 3: Manage pharmaceutical rebate contracting.
- Understand the principles of formulary rebate contracting with pharmaceutical manufacturers.
- Differentiate between different types of rebates (e.g., flat, market share-based).
- Analyze a rebate contract to ensure its terms are favorable and auditable.
- Validate that all earned rebates have been collected from manufacturers.
- Analyze the impact of rebates on the net cost of drugs in a therapeutic class.
Task 4: Understand and apply drug pricing benchmarks and models.
- Define and differentiate between key pricing benchmarks (AWP, WAC, ASP, NADAC).
- Understand how different benchmarks are used in pharmacy reimbursement and rebate calculations.
- Analyze the spread between different pricing benchmarks and its financial implications.
- Understand how Maximum Allowable Cost (MAC) pricing is used to reimburse for generic drugs.
- Differentiate between transparent, pass-through, and spread pricing models.
Task 5: Analyze and manage specialty drug spend.
- Define what constitutes a specialty drug based on cost, complexity, and other factors.
- Analyze data to identify the key drivers of specialty drug trend.
- Develop and implement strategies to manage specialty drug utilization and cost.
- Evaluate the impact of site-of-care programs for provider-administered specialty drugs.
- Differentiate management strategies for medical benefit versus pharmacy benefit specialty drugs.
Task 6: Design and evaluate value-based contracts.
- Differentiate between traditional rebate contracts and value-based or outcomes-based contracts.
- Identify appropriate disease states and drugs for value-based contracting.
- Design contract terms based on measurable clinical or economic outcomes (outcomes-based drug rebates).
- Evaluate the data infrastructure required to track and measure outcomes.
- Assess the operational feasibility and financial risk of implementing a value-based contract.
Domain 4: Quality, Clinical Programs, and Member Relations (15%)
Task 1: Manage Medication Therapy Management (MTM) programs.
- Understand the CMS requirements for the Medicare Part D MTM program.
- Develop and manage the eligibility criteria for MTM services.
- Oversee the delivery of Comprehensive Medication Reviews (CMRs) and Targeted Medication Reviews (TMRs).
- Measure and report on the outcomes of the MTM program.
- Ensure that MTM services are delivered in a cost-effective and compliant manner.
Task 2: Manage programs to improve quality scores.
- Develop and implement programs to improve performance on medication-related quality measures (e.g., HEDIS, Star Ratings).
- Design targeted interventions to improve medication adherence for chronic conditions.
- Implement programs to reduce the use of high-risk medications in the elderly.
- Collaborate with providers to close gaps in care related to medication use.
- Analyze data to identify the members and providers who are driving poor performance.
Task 3: Manage member grievance and appeals processes.
- Ensure the organization has a compliant process for handling member grievances and appeals.
- Differentiate between a grievance, a coverage determination, and an appeal.
- Oversee the clinical review of appeals for denied services.
- Ensure all decisions are made within the required regulatory timeframes.
- Analyze appeals data to identify opportunities to improve benefit design or communication.
Task 4: Integrate health equity and social determinants of health (SDOH) into benefit design.
- Analyze pharmacy data to identify health disparities among different member populations.
- Design benefit structures that reduce barriers to access for underserved communities.
- Integrate programs that address SDOH, such as medication delivery or nutritional support, with the pharmacy benefit.
- Ensure member communications are culturally competent and available in multiple languages.
- Evaluate the impact of clinical programs on reducing health disparities.
Task 5: Evaluate and integrate digital health solutions.
- Assess the clinical and financial value of digital therapeutics and mobile health applications.
- Integrate digital health solutions and remote monitoring into clinical programs to support medication adherence and disease management.
- Evaluate the role of telepharmacy in improving member access to clinical services.
- Ensure that any integrated digital health tools are compliant with privacy and security standards.
- Develop strategies for the reimbursement and formulary placement of digital therapeutics.
Task 6: Ensure compliance with behavioral health parity requirements.
- Apply the Mental Health Parity and Addiction Equity Act (MHPAEA) to the pharmacy benefit.
- Analyze utilization management criteria and benefit design to ensure parity between medical/surgical and mental health/substance use disorder benefits.
- Conduct and document comparative analyses of non-quantitative treatment limitations (NQTLs).
- Ensure that there are no separate, discriminatory treatment limitations applied to mental health conditions.
- Remediate any identified parity violations in the benefit design or operations.
Domain 5: Regulatory, Compliance, and Audit Oversight (15%)
Task 1: Manage compliance with CMS Medicare and Medicaid regulations.
- Oversee the annual formulary submission and review process for Medicare Part D.
- Manage compliance with regulations for transition fills, protected classes, and other coverage requirements.
- Differentiate and manage the specific compliance requirements for Medicaid managed care pharmacy benefits.
- Ensure all member and provider communications meet CMS marketing guidelines.
- Prepare for and manage CMS and state Medicaid program audits of the pharmacy benefit.
Task 2: Manage compliance with state PBM laws, FTC rules, and ERISA.
- Apply state-specific laws governing PBM practices, such as MAC pricing transparency and fiduciary duties.
- Monitor and ensure compliance with Federal Trade Commission (FTC) investigations and transparency rules.
- Differentiate the regulatory requirements for fully insured versus self-funded (ERISA) employer plans.
- Apply ERISA principles and fiduciary responsibilities to the management of employer-sponsored plans.
- Monitor the evolving landscape of state and federal PBM legislation.
Task 3: Oversee fraud, waste, and abuse (FWA) monitoring.
- Design and manage a comprehensive FWA program for the pharmacy benefit.
- Apply the federal Anti-Kickback Statute and False Claims Act to PBM and pharmacy operations.
- Use data analytics to identify and investigate suspicious patterns of prescribing, dispensing, or billing.
- Manage the process for reporting potential FWA to the OIG and other government agencies.
- Ensure all employees and downstream entities complete required FWA training.
Task 4: Manage HIPAA and data privacy in a PBM context.
- Apply the HIPAA Privacy and Security Rules to the large-scale use of pharmacy claims data.
- Oversee the execution and management of Business Associate Agreements with clients and vendors.
- Manage the de-identification and use of data for analytics and research.
- Develop and manage an incident response plan for data breaches.
- Ensure compliance with state-specific data privacy laws.
Task 5: Prepare for and manage client and regulatory audits.
- Develop a state of continuous readiness for audits from clients, regulators (CMS, state DOI), and accreditation bodies.
- Manage the collection and submission of all requested audit documentation.
- Serve as the subject matter expert and primary point of contact during an audit.
- Develop and implement corrective action plans (CAPs) to address any audit findings.
- Track and report on the resolution of all audit findings to leadership.
