36C10X18R0134-00002000.docx

5. PROJECT NUMBER (if applicable)

CODE

7. ADMINISTERED BY

2. AMENDMENT/MODIFICATION NUMBER

CODE

6. ISSUED BY

8. NAME AND ADDRESS OF CONTRACTOR

4. REQUISITION/PURCHASE REQ. NUMBER

3. EFFECTIVE DATE

9A. AMENDMENT OF SOLICITATION NUMBER

9B. DATED

PAGE

OF PAGES

10A. MODIFICATION OF CONTRACT/ORDER NUMBER

10B. DATED

BPA NO.

1. CONTRACT ID CODE

FACILITY CODE

CODE

Offers must acknowledge receipt of this amendment prior to the hour and date specified in the solicitation or as amended, by one of the following methods:

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

E. IMPORTANT:

is extended,

(a) By completing Items 8 and 15, and returning __________ copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or electronic communication which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY is not extended.

12. ACCOUNTING AND APPROPRIATION DATA

(REV. 11/2016)

is required to sign this document and return ___________ copies to the issuing office.

is not, A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT ORDER NO. IN ITEM 10A.

15C. DATE SIGNED

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

RESULT IN REJECTION OF YOUR OFFER. If by virtue of this amendment you desire to change an offer already submitted, such change may be made by letter or electronic communication, provided each letter or electronic communication makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER

BY

Contractor

16C. DATE SIGNED

14. DESCRIPTION OF AMENDMENT/MODIFICATION

16B. UNITED STATES OF AMERICA

Except as provided herein, all terms and conditions of the document referenced in Item 9A or 10A, as heretofore changed, remains unchanged and in full force and effect.

15A. NAME AND TITLE OF SIGNER

16A. NAME AND TITLE OF CONTRACTING OFFICER

15B. CONTRACTOR/OFFEROR

STANDARD FORM 30

PREVIOUS EDITION NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.243 (Type or print) (Type or print) (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

(Number, street, county, State and ZIP Code) (If other than Item 6) (Specify type of modification and authority) (such as changes in paying office, appropriation date, etc.)

(If required)

(SEE ITEM 11)

(SEE ITEM 13)

(X)

CHECK

ONE

13. THIS ITEM APPLIES ONLY TO MODIFICATIONS OF CONTRACTS/ORDERS,

IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

(Signature of person authorized to sign) (Signature of Contracting Officer) 00002 05-29-2018

NONE

Strategic Acquisition Center - Frederick Department of Veterans Affairs 321 Ballenger Center Drive, Suite 125 Frederick MD 21703 Strategic Acquisition Center - Frederick Department of Veterans Affairs 321 Ballenger Center Drive, Suite 125 Frederick MD 21703 To all Offerors/Bidders

36C10X18R0134 05-17-2018

X X X See A.1 CONTINUATION PAGE for details.

Table of Contents

A.1 CONTINUATION PAGE

The purpose of this amendment is to:

A. Provide questions received in response to the solicitation and Government responses (#1-31, below):

1. Would the Veterans Administration extend the proposal due date to June 15, 2018.

RESPONSE: The due date was extended to June 14, 2018 via Amendment 00001 to provide a reasonable timeframe for responses after the Q&A is issued.

2. Is participation of an SDVOSB or VOSB a mandatory contract requirement?

RESPONSE: This acquisition is unrestricted and participation with an SDVOSB or VOSB contractor is not mandatory; however, participation credit will be evaluated in accordance with None-price factor: Socio-Economic Consideration.

3. Pharmacy contracts for Workers Compensation RFPs typically given 2 weeks for bidder’s questions and 6 weeks for the response. This is due to complexity of Workers Compensation requirements and IT security requirements. Will you extent the RFP deadline to 6 weeks?

RESPONSE: See response to Question #1.

4. Who is the incumbent for the VA Workers Compensation contract today?

RESPONSE: Coventry Health Care Workers Compensation, Inc.

5. Given the requirement for “…HIPAA, Privacy Act, FISMA, NIST, FIPS, and VA security and privacy directives and handbooks…” it will take 6+ months for any new contractor to implement these standards. Will you level the playing field by extending the implementation timeframe to 6 – 9 months?

RESPONSE: After the contract is awarded, the security and privacy measures must be in place within 30-days. Due to VA’s immediate business needs programs need to be operational within 60-days to support the provision of this benefit for the injured worker with minimal disruption.

6. In all pharmacy contracts it is necessary to post deidentified pharmacy claims with NDCs, NPIs, days’ supply, GPIs, and other non-HIPAA fields. Without this data all non-incumbent contractors are at a material disadvantage from a pricing perspective. Will you please provide all pharmacy claims with fields requested with a minimum of 3 weeks after posting the data for contractors to model and price the data?

RESPONSE: The attached detail is what is available for offeror analysis. Contractors are expected to determine what FECA discount below AWP is and determine the amount of discount they can offer below FECA. See Attachment D.3 ATTACHMENT C: CASE MANAGEMENT PRICE MODEL for a sample of deidentified claims.

7. A RFP of 60+ pages plus thousands of pages of references and FAR requirements requires 2 weeks to go through the detail and determine if we have further questions. Pulling our questions together in 2 business days is not enough time to understand what we are bidding on in total. Would you be willing to consider two rounds of bidder’s questions and the ability to ask questions up to close to the bid? Contractors want to ensure alignment with government expectations. We request that you extend the first round of questions to June 8 and give us 10 business days after your first response to ask our second round of questions. Then when we receive your second round of responses, give us 4 weeks to finalize our solutions and price. In order for contractors to integrate government answers into our proposals, would you be willing to extend the response period to 90 days? This will give all competitors a level playing field to put forward comprehensive and cost competitive proposals.

RESPONSE: See response to Question #1.

8. The RFP notes the initial Period of Performance is June 29, 2018 - June 28, 2019. Is June 29, 2018 intended to be the effective date for the program? If so, please advise on the timeline for finalist notification, award, and implementation start dates. The implementation timeframe is likely only achievable for the incumbent contractor and therefore the requirement may dissuade competition. Would the Government be willing to extend the implementation time period to 6 months?

RESPONSE: The intent of the Post Award Kick-Off Meeting is not only to discuss the PWS, tasks and deliverables; accountability and responsibility to include the Quality Assurance Surveillance Plan (QASP) for each task and deliverable; risk identification and mitigation controls, but also discuss how the Contractor will accomplish the tasks outlined in this Performance Work Statement, Section 5.0 and 7.0. The work plan is to include implementation milestones is due within five business days after the kick-off meeting. Due to the VA immediate business needs programs need to be operational within 30 – 60 days to support the provision of this benefit for the injured worker with minimal disruption. See Attachment D.4 ATTACHMENT D: EXAMPLE IMPLEMENTATION TIMELINE.

9. The start date of 6/29/2018 assumes all contractors have systems, data interfaces, applications, IT security, and other requirement already in place. While worker comp contractors have core infrastructure in place, requirements in this RFP will take significant time to design, develop, and test. Will you consider a 6-month phase in period?

RESPONSE: See response to Question #8.

10. The RFP notes that questions and comments on the RFP are due by 10:00 a. ET on May 21. Please advise when responses to bidder questions will be shared with bidders and that the timing of responses will be sufficient to allow bidders to adjust their responses accordingly.

RESPONSE: All questions and responses are provided in this amendment.

11. The May 29 due date for responses allows offerors only 7 business days to assess, price, and build a competitive proposal offering. Given the complexity of this proposal, this short turnaround time is likely to be exceedingly challenging for all offerors and may dissuade qualified and exceptional offerors from bidding, which is not in the Government’s interest. The Government would benefit from allowing offerors more time to prepare proposals as it would likely increase competition, which drives prices lower, and the Government would receive much higher quality proposals. Would the Government be willing to extend the proposal due date to 30 days from RFP issuance?

RESPONSE: See response to Question #1.

12. The RFP requests bidders provide information on past performance of three current or previous contracts using the Past Performance Questionnaire Form. Since we are unable to ensure our clients will submit the requested form to the Contracting Officer in the format and within the timing requested, are bidders able to request past performance questionnaires from more than three clients? Asking clients to provide past performance questionnaire responses can be an imposition on their time and often takes 3+ weeks to coordinate the response. Will you be willing to accept questionnaire responses 2 weeks after the final RFP response?

RESPONSE: Offerors may request Past Performance Questionnaires from more than three references; however, PPQs are only to be submitted for the three contracts identified and described in the offeror’s Performance Risk volume. Section E.1.8.b, Section IV: Past Performance Questionnaires (PPQs) is updated in the following pages.

13. Please provide clarification around pricing expectations for DME (e.g., tests, x-ray, medical, radiology, exam, transportation, language, speech therapy, etc.). What other services are included in DME? Is the pricing expected to vary by region or complexity, or should the offeror offer one price?

RESPONSE: (DME) (walkers, crutches, canes, splints, muscle stimulators, etc.), physical therapy and diagnostic services (Magnetic Resonance Imaging (MRI), Computerized Tomography Scans (CT), Radiology, X-Rays, Electromyogram (EMG), and Nerve Conduction Velocity (NCV) studies. DME will achieve cumulative savings below FECA. DME pricing varies geographically and not based on Average Wholesale Price (AWP). Contract does not include transportation and language or speech therapy for DME services. See Attachment D.2 ATTACHMENT B: PRICE MODEL – REV.1

14. The implementation phases are faster than the industry standard of 90 – 180 days depending on complexity. We believe this expedited implementation provides any incumbent contractor a competitive advantage against non-incumbent bidders. Will you be willing to change the implementation schedule to:

90 days post award:

· Pharmacy Benefit Management Services

· PBM Utilization Review – Will be available within 60 days

· Security – NIST800-53 ß Required for ATO

· Fee Schedule

· Customer Support

· Eligibility Verification

· Fraud, Waste, and Abuse

· Reporting

· Information Management (Data Retention)

· Formulary Management Services

· Prior Authorization Portal

· Specialty

180 days post award:

· Durable Medical Equipment (DME)

· Diagnostic Services & Testing

· Patient Compliance Program

· Disease Management Program

Although HIPAA is not applicable to workers’ compensation, our organization does comply with all applicable workers’ compensation rules and regulations, including Health Information Trust Alliance (HITRUST) certification and SSAE 18, SOC 1, Type II attestations. We also plan to conduct an attestation in accordance with Statement on Standards for Attestation Engagements No. 18 (SSAE 18) for the period beginning January 1, 2019 and will provide the Service Organization Control (SOC) 2, Type II report upon completion, if awarded the contract. Would the Department of Labor consider these certifications and attestations in place of HIPAA compliance?

RESPONSE: See response to Question #8. Where applicable, the contractor shall ensure that data is handled in a manner that is compliant with security measures that HIPAA rules may require 30-days from award of contract.

15. Is the FY17 pharmacy spend noted on Page 5 of the solicitation accurate ($21,971)?

RESPONSE: No, the correct the amount is $21,971,050 for pharmacy spend. See updated SECTION B.3 PERFORMANCE WORK STATEMENT.

16. Will you accept a minimum of 3 years of experience providing pharmacy benefit management services (PBM) to the Federal government plus a minimum of 3 years of experience providing workers’ compensation PBM services to state governments as meeting Requirement #1 stated in the solicitation?

RESPONSE: Experience is required as outlined in the solicitation.

17. With the exception of “First Fills” that are later deemed non-compensable, should the PBM expect full reimbursement for all prescriptions filled?

RESPONSE: The PBM should normally expect reimbursement at the full discounted rate as required by the contract for prescriptions approved by OWCP.

18. Reference: Page #5, Clause #4, Requirement: Eligibility Question: It is standard for the client to provide a one-time eligibility data load prior to go-live, in addition to regular (daily) eligibility feeds to keep the eligibility data up to date. Can VA elaborate on their expectations of providing this data?

RESPONSE: OWCP provides VA with our billpay/case management files approximately every two weeks. VA will make this data available in a secure manner to the contractor for the purpose of executing the contract requirements.

19. Reference: Page #5-6, Clause # 1, 4, Requirement: Can securely transfer electronically all prescription information between participating network pharmacy, PBM, and OWCP. The contractor shall submit bills electronically to OWCP at point of sale.

Question: This is standard practice assuming VA is communicating that OWCP would need a feed (of some kind) at point of sale or fulfillment. Additionally, we have flexible pricing and billing cycle to support our clients' needs. What interfaces does VA anticipate will be required between VA/OWCP and Contractor?

RESPONSE: Please refer to the work flow under #25, SECTION B.3 PERFORMANCE WORK STATEMENT, 5. REQUIREMENTS OBJECTIVES (page #8 of the solicitation).

20. Reference: page # 10, 11, 15, Requirement: Review & Reporting, Drug Review & Reporting, Reporting

Question: Can VA elaborate on the type of reporting expected or will our standards suffice?

RESPONSE: The specific format and content of these reports shall be worked out by the VA COR and the Contractor's Program Manager. Reporting content is outlined in SECTION B.3 PERFORMANCE WORK STATEMENT, 7. PERFORMANCE OBJECTIVES TASK AND DELIVERABLES, Task 6: Management Information Reports.

21. Reference: Claims History Data.

Question: It is standard for the client to provide historical claims data for the eligible beneficiaries in order to run proper DUR as well as proper claims adjudication. Does the VA anticipate being able to do this?

RESPONSE: Yes. The contractor will be provided access to VA OWCP billpay/case management files after award.

22. Reference: Kick-Off/Prior to Go-Live

Question: It is standard for a client to provide data prior to go-live in order to support proper adjudication and billing. These include Eligibility, Prior Authorizations, Prescriber files in addition to having aligned with our client on billing/pricing model as well as standard reporting. Could VA elaborate on these standards they meet today so we can elaborate on how our best practices could meet or exceed your standards?

RESPONSE: The contractor will be provided access to VA OWCP billpay/case management files prior to go-live implementation of the program.

23. Reference: Six-month CLINs rather than traditional 1 year CLINs

Question: Reasoning for 6-month CLINs rather than 1 year CLINs. If you foresee a potential early termination of this agreement and/or moving patients to another contract, please explain the risk. We need to price accordingly if there is a chance the contract will not have all option years exercised.

RESPONSE: Please reference C.2 FAR 52.212-4, Contract Terms and Conditions Commercial Items, ADDENDUM.

24. Reference: Page #5, Clause #4, Requirement: Eligibility

Question: It is standard for the client to provide a one-time eligibility data load to ESI prior to go-live, in addition to regular (daily) eligibility feeds to keep the eligibility data up to date. Can VA elaborate on their expectations of providing this data?

RESPONSE: The Contractor will be provided the VA bill pay/case management file after the award and security is in place.

25. Reference: Page #5-6, Clause # 1, 4, Requirement: Can securely transfer electronically all prescription information between participating network pharmacy, PBM, and OWCP. The contractor shall submit bills electronically to OWCP at point of sale.

Question: This is standard practice assuming VA is communicating that OWCP would need a feed (of some kind) at point of sale or fulfillment. Additionally, we have flexible pricing and billing cycle to support our clients' needs. What interfaces does VA anticipate will be required between VA/OWCP and Contractor?

RESPONSE: VA does not require an interface with the contractor. Standard practice for communication purposes between network pharmacy, PBM, and OWCP.

26. Reference: page # 10, 11, 15, Requirement: Review & Reporting, Drug Review & Reporting, Reporting

Question: Can VA elaborate on the type of reporting expected or will our standards suffice?

RESPONSE: See response to Question #20..

27. Reference: Claims History Data

Question: It is standard for the client to provide historical claims data for the eligible beneficiaries in order to run proper DUR as well as proper claims adjudication. Does the VA anticipate being able to do this?

RESPONSE: The Contractor will be provided the VA bill pay/case management file after the award and security is in place.

28. Reference: Kick-Off/Prior to Go-Live

Question: It is standard for a client to provide data prior to go-live in order to support proper adjudication and billing. These include Eligibility, Prior Authorizations, Prescriber files in addition to having aligned with our client on billing/pricing model as well as standard reporting. Could VA elaborate on these standards they meet today so we can elaborate on how our best practices could meet or exceed your standards?

RESPONSE: The Contractor will be provided the VA bill pay/case management file after award and security is in place. Please see Attachment D.3 ATTACHMENT C: CASE MANAGEMENT PRICE MODEL.

29. Reference: Six-month CLINs rather than traditional 1-year CLINs

Question: Reasoning for 6-month CLINs rather than one-year CLINs. If you foresee a potential early termination of this agreement and/or moving patients to another contract, please explain the risk. We need to price accordingly if there is a chance the contract will not have all option years exercised.

RESPONSE: Please reference C.2 FAR 52.212-4, Contract Terms and Conditions Commercial Items, ADDENDUM.

30. In accordance with FECA law, any requests for DME may require up to two estimates. If DOL should require an estimate, the contractor shall provide the requested estimate to DOL. If DOL approves the contractor’s submitted estimate and if the contractor is voluntarily selected by the claimant, the contractor shall be able to provide efficient, accurate, and timely processing of DME requests to the claimant.

Rationale:

Historically requiring two DME estimates is a rarity. It takes much more time and labor intensive.

Question A: Under what circumstances would the DOL require up to two estimates for DME?

RESPONSE: The authorization request cost seems excessive for the geographical location would likely be the reason. There is no explanation in the regulations, the reason would be case specific.

Question B: How will these requests for estimates be communicated to the Contractor so that the Contractor can provide the requested estimate(s) prior to fulfilling the DME order?

RESPONSE: Electronically in response to the authorization request submitted in the ACS portal.

31. There was no definition for Pricing Model Attachment B Column “C” in which it states “Estimated Dollar Volume”. Is this the actual dollar volume with FECA rates applied or another amount? Without this information it is difficult to establish an “apples to apples” comparison using this spreadsheet.

RESPONSE: These estimated amounts are based on FY17 spends.

B. Update SECTION B.3 PERFORMANCE WORK STATEMENT (All changes are notated in BLUE for ease of reference);

C. Update SECTION D.2 ATTACHMENT B: PRICE MODEL. See ATTACHMENT B: PRICE MODEL_REV.1;

D. Include SECTION D.3 ATTACHMENT C: CASE MANAGENT PRICE MODEL; and

E. Include SECTION D.4 ATTACHMENT D: IMPLEMENTATION TIMELINE EXAMPLE

There are no other changes to this solicitation.

Page 1 of

SECTION B – CONTINUATION SF 1449 BLOCKS

B.3 PERFORMANCE WORK STATEMENT

The Department of Veterans Affairs (VA) employs a workforce of approximately 380,000 Federal civilian employees. There were approximately 15,000 VA cases under active case management in FY 17. These cases generated $21,971,050 in prescription costs and $37,553,546 in durable medical equipment (DME), Imaging, diagnostic services, and physical therapy costs on the VA Chargeback in FY 2017.

Based on an average of this historical data, the annual estimated cost is $70,663,998, and the total estimated cost for a three-year contract is $211,991,994. In Fiscal Year (FY) 2017, VA's Pharmacy Benefit Management (PBM) Program saved approximately $1,750,000 in medical costs on the VA Workers’ Compensation (WC) Chargeback Report. The current participation rate is 90 percent.

2. PURPOSE

The VA is seeking an expert and experienced Contractor, specializing in federal WC, to support the PBM Program or WC. The PBM Program will be a national program for VA employees who are injured on the job, and require prescription medications, durable medical equipment (DME) (walkers, crutches, canes, splints, muscle stimulators, etc.), physical therapy and diagnostic services (Magnetic Resonance Imaging (MRI), Computerized Tomography Scans (CT), Radiology, X-Rays, Electromyogram (EMG), and Nerve Conduction Velocity (NCV) studies. The function of the PBM is to provide a more efficient way for employees who are injured on the job to obtain the services they need, without the need to save receipts or file reimbursement forms.

3. PERIOD OF PERFORMANCE

The estimated contract Period of Performance (PoP) is for a 6-month base period starting on June 29, 2018, through December 29, 2018, with five 6-month option periods (three years total if all options are exercised).

4. ELIGIBILITY

There are two groups of VA employees eligible for coverage under this program.

1. Group 1 is comprised of those who have an existing claim under the FECA. These employees have fully adjudicated WC claims, and have coverage for all prescriptions that meet the OWCP requirements for their accepted injury.

1. Group 2 is comprised of new FECA claimants. These employees are newly injured on the job and have filed FECA claims pending adjudication by OWCP.

VA requires that the PBM Program provide a system for first-fill prescription coverage for employees who sustain a traumatic injury at work. The PBM Program will provide a pharmacy card system to these employees as part of the VA injury packet. Full prescription coverage for the work-related traumatic injury will be provided to all injured employees upon filing a FECA claim for traumatic injury. The VA anticipates 95 percent of these claims will be approved and all prescription costs covered by OWCP.

5. REQUIREMENT OBJECTIVES

The successful Contractor, at a minimum, shall demonstrate the following objectives to operate the PBM Program, to include, but not limited to:

1. Three years' experience in providing PBM services, Experience specializing in federal WC in conjunction with OWCP is required.

2. Can assign a single program manager full-time to support the VA account with at least five years' experience managing a PBM program. Federal PBM WC program experience is desirable.

3. Has national access to pharmacy chains and a majority of other pharmacies with a minimum of 65,000 network pharmacies during the contract term to meet the needs of VA.

4. Can securely transfer electronically all prescription information between participating network pharmacy, PBM, and OWCP. The contractor shall submit bills electronically to OWCP at point of sale.

5. At a minimum, has established a claims processing system that will conform to the National Council for Prescription Drug Programs (NCPDP) standards. The Contractor shall validate NPI number and DEA number to ensure physicians and pharmacies are registered. The Contractor shall be able to report NPI, DEA, and other related information to Government upon request.

6. At a minimum, can bill for prescriptions using the 11-digit National Drug Code (NDC) Number.

7. Can provide a pharmacy program to potentially eligible VA employees. This method is required by OWCP and limited to VA employees.

8. Has the ability to provide a voluntary mail order program option for any VA employee to utilize when requesting this service. The Contractor shall send out information packets to eligible VA employees to inform them of the voluntary mail order option and instructions for requesting this service.

9. Can administer an International Classification of Disease (ICD) 10 code in accordance with and as determined by OWCP.

10. Has the ability to provide a Review and Reporting (RR) Program to include the information necessary to process the bill. The contractor shall obtain access to and use various excluded provider lists (e.g., HHS excluded provider and similar state lists) to deny payment to providers included on those lists. Additionally, Government will provide a list of entities for which payments should not be made. The contractor shall neither pay (nor seek reimbursement for) pharmacy or DME bills for the entities identified by the contractor on these lists, by the Government, or as otherwise suspended or debarred. The contractor shall provide ongoing monitoring to ensure such providers are not part of the network.

11. Can implement a Drug Review and Reporting (RR) Program and must include at a minimum the following:

a. Detection of fraud and abuse patterns by providers or employees

b. Screening for drug/drug contraindications, drug/age, contraindications, drug/pregnancy contraindications

c. Duplicate prescriptions

d. Therapeutic overlap

e. Early refill

f. Prospective, concurrent, and retrospective RR program specific to, but not restricted to, opioids, letters of medical necessity, and excessive costs.

12. Can implement Formulary Administration and a therapeutics committee with ability to develop and administer one or more ICD-10 code based formularies in accordance with and as determined by OWCP.

13. Can provide PBM services to support about 380,000 employees of which about 18,000 employees receive prescriptions, durable medical equipment and diagnostic services as a benefit of the WC program.

14. In accordance with FECA law, any requests for DME may require up to two estimates. If DOL should require an estimate, the contractor shall provide the requested estimate to DOL. If DOL approves the contractor’s submitted estimate and if the contractor is voluntarily selected by the claimant, the contractor shall be able to provide efficient, accurate, and timely processing of DME requests to the claimant.

15. Assure accurate and timely report inquiries. The contractor shall ensure that all bill, claimant, provider, pharmacy, drug, and DME-related data used for processing the bill may be shared with the Government.

16. Regular monitoring of rental to ownership conversion for DME, with 100% of the rental costs applied to purchase (Hearing aids are defined as DME for the purposes of the Federal Employees’ Compensation Program.)

17. Can implement reimbursement for duplicate bill payment, monitor providers for billing outside of network, and capture billing outside of network.

18. Can bill for all DME items using definable and/or acceptable coding, and in accordance with OWCP regulations and procedures.

19. Can ensure contracted discount rate below FECA fee schedule is used for generic and brand-named drugs, compounded drugs, and specialty drugs. Diagnostic services and DME items, will achieve a cumulative savings rate below FECA fee schedule.

20. Has access to medical imaging and testing networks, chains or suppliers sufficiently to affect a minimum penetration rate, based on dollars, as mutually agreed to during contract term.

21. Can bill for medical imaging and testing services using Procedure Coding: Billings for medical services subject to the OWCP fee schedule must be identified according to the American Medical Association Physicians' Current Procedural Terminology coding scheme (CPT), the Healthcare Common Procedure Coding System (HCPCS), including the American Dental Association Codes (ADA), or designated OWCP generic codes. The applicable coding rules should be followed as appropriate, including the use of correct CPT and HCPCS modifiers. Use of non-specific or “unlisted” codes to identify procedures clearly described by a CPT code will be denied. OWCP now uses a correct coding initiative program that is based on the CMS model, and separately billed components of services also billed under comprehensive codes will be rejected. https://www.dol.gov/owcp/regs/feeschedule/fee/feeSept3017/Effective_September_30_2017_Read_Me_First.htm

22. Provide dedicated and security-cleared customer service representatives for VA job-injured employees to access 24/7 to enroll in the PBM, provide information regarding network pharmacies, claim, drug information, payments, and request authorizations for services via the ACS portal, etc.

23. Will institute performance metrics every 30 days, to measure the effectiveness of the contract.

24. Comply with The Health Insurance Portability and Accountability Act of 1996 (I-IIPAA), Public Law 104-191, and The Privacy Act of 1974 (Pub.L. 93-579, 88 Stat. 1896, enacted December 31, 1974, 5 U.S.C.. § 552a),

25. Able to provide a work flow like the one outlined below:

Pharmacy provider enters prescription into the Point of Sale System

Pharmacy transmits electronic bill to PBM via National Switch

PBM reviews bill, assigns fee schedule for drug charge, and transmits prescription with charge to OWCP via National Switch (NDC) and Department of Labor's (DOL) Bin Number (008787)

OWCP adjudicates claim and returns it through National Switch (NDC) to PBM, authorizing payment for prescription submitted

PBM notifies pharmacy of OWCP approval through National Switch Pharmacy provides prescription to employee

Independent of VA, PBM pays pharmacy based on previously negotiated fee schedule

6. AGENCY RESPONSIBILITIES

Post Award Kick-Off Meeting

To better understand VA's organizational and cultural environment within five working days from the date of contract award, the VA will host a Post Award Kick-Off Meeting. The intent of the Post Award Kick-Off Meeting is not only to discuss the PWS, tasks and deliverables; accountability and responsibility to include the Quality Assurance Surveillance Plan (QASP) for each task and deliverable; risk identification and mitigation controls, but discuss how the Contractor will accomplish the tasks outlined in this Performance Work Statement, section 5.0 and 7.0. The VA will provide the Contractor with an orientation and briefing, as well as a range of documentation and material that will provide an overview of VA's organizational structure, mission, and goal, the assigned WC program staff, their locations, and their current duties and responsibilities.

This documentation will include:

1. Organization charts, including the current roles and responsibilities for all the organizations within the Department, and

1. Identification of the COR for technical program direction under the scope of work executed by contract.

Upon award of the contract, the agency will be responsible for the following:

1. Notifying DOL OWCP within five days after contract award of the selected Contractor. The Contractor shall not perform Inherently Governmental Functions as prescribed in Federal Acquisition Regulation (FAR) 7.503.

1. Except for the contract/discount price, such pharmacy services must be provided in accordance with OWCP rules for such services. No formularies or other restrictions can be imposed by VA or their contractor. VA bears responsibility to assist in the development of the claim; to assist the employee with the FECA claims process; and fully bears the ultimate responsibility for the entire financial costs of the FECA claim through the FECA chargeback process. The PBM program will be entirely voluntary for VA employees; VA will allow OWCP to review the program materials provided to employees and their claimants, and VA agrees to undertake the responsibility to provide claimants with information relative to the provision of the voluntary PBM program.

The VA COR will monitor contractor’s performance to ensure quality, timeliness, and compliance with the contract terms. The contractor’s performance will be reported on an annual basis to the Contractor Performance Assessment Reporting System (CPARS) by the VA COR and CO. Poor performance may result in issuance of a Contractor Discrepancy Report (CDR). The CO and COR will make use of information from CDRs, as well as any additional knowledge and information available to them with respect to the contractor’s performance, to complete the CPARS.

The COR will review the progress reports and management information reports in comparison with bill pay file reports received from OWCP (bills that OWCP has approved/paid for VA claimants) to ensure all bills the contractor submits to OWCP for VA claimants are in accordance to the discounts and fees negotiated under this contract. Instances of over-payment due to incorrect billing or over-charges by the contractor shall be reported by the VA COR to OWCP and the CO immediately upon finding. Incorrect billing or over-charging will result in the issuance of a CDR to the contractor by the Contracting Officer, requiring a response from the contractor within the time period given in the CDR, and may impact assessment of the contractor’s performance. The contractor agrees to correct and/or reimburse the Government for over-payments in a way determined appropriate by VA and OWCP.

7. PERFORMANCE OBJECTIVES TASK AND DELIVERABLES:

The Contractor shall provide the following tasks and deliverables in support of the Pharmacy Benefit Management Program contract:

Task 1: Post-Award Orientation and Kick-Off Meeting

The contractor shall work with the Government to coordinate and facilitate the kickoff meeting, provide meeting agenda and Work Plan that identifies all tasks, resources utilized (i.e., number, labor category, and description), deliverables to be completed, and the corresponding timetable/delivery dates.

1a. Deliverable: Coordinate and facilitate the meeting, and provide meeting agenda within five business days after the contract has been awarded.

1b. Deliverable: Within five business days after the kick-off meeting, the Contractor shall submit the Work Plan in both hard-copy and electronic forms to the COR. Format requirements include letter size paper (8 1/2" x 11"), Arial 12 font, created in a program compatible with Microsoft Office 2007 programs.

Task 2: Establishing a Contractor Program Manager

Appoint and electronically notify the COR of the name and contact information of its authorized Contractor Program Manager (PM) who shall be the primary interface with VA's COR on current PBM contract performance.

2a. Deliverable: Establish a Contractor Program Manager within 5 business days after contract award.

Task 3: Meetings with the VA COR/WC PM

Discuss the progress of the VA PBM with the VA COR, PM and VA management officials no less than quarterly, and as needed, per request by VA COR. These meetings will be scheduled by the COR. Scheduled meeting may take place in person, during on-site visits or via conference calls.

3a. Deliverable: Establish a meeting schedule within five business days after contract award.

Task 4: Quality Control

Develop and implement internal quality control procedures that produce timely, accurate, complete and relevant data that meets the full requirements of this performance work statement. An evaluation of the PBM system will be conducted will be conducted by the COR, as required to ensure that efficient and effective management processes remain in place and that data is handled in a secure manner and protected to meet all the FECA and Privacy Act requirements as well as VA information security requirements. Contractor shall ensure that the information is maintained consistent with all Privacy Act requirements, and shall ensure that its information security safeguards are consistent with OWCP policies and practices. Where applicable, the contractor shall ensure that data is handled in a manner that is compliant with security measures that HIPAA rules require.

4a. Deliverable: The Contractor shall develop and implement internal quality control procedures immediately upon award of contract. The Government will develop a Quality Assurance Surveillance Plan (QASP) after award.

Task 5: Progress Reports

Develop and provide monthly progress reports to the VA COR. The specific format and content of these reports shall be developed by the Contractor and approved by the VA COR. In general, the PBM reports should include summary information that enables VA management to make key decisions about the direction of the WC PBM. The scope, content, and format of these reports will be agreed upon between the VA COR and the Contractor Program Manager.

5a. Deliverable: The Contractor shall submit the management information reports in hard-copy and electronic final form to the COR monthly by the third Wednesday of the month. In the event of a holiday or closure due to an Executive Order, reports shall be due the next business day.

Task 6: Management Information Reports

Develop and provide monthly progress reports to VA COR submitted by the third Wednesday of the month. In the event of a holiday or closure due to an Executive Order, reports shall be due the next business day. The specific format and content of these reports shall be worked out by the VA COR and the Contractor's Program Manager.

In general, the Contractor shall include summary information that enables VA's management to make key decisions about the direction of the PBM Program. The Contractor shall submit a draft progress report template for review and approval by the VA COR. In addition to the monthly progress reports outlined above, the Contractor shall provide management information reports to the VA COR.

6a. Deliverable: Aggregate data and information on VA cases reflecting the number of cases in which PBM services were provided, clearly identifying the type of service (prescription, DME, or imaging).

6b. Deliverable: Periodic information on any cost savings achieved through the Contractor management of the PBM, including actual and cost avoidance savings on medical costs.

6c. Deliverable: Maintain, retain, and make available complete and accurate bill payment and financial reporting history.

6d. Deliverable: Provide timely and accurate reports including the tracking/monitoring of program utilization, cost savings, and performance metrics against program goals.

6e. Deliverable: Provide reports and statistics for quality reviews.

6f. Deliverables: Report cost savings and utilization at district and area level of the VA organization.

6g. Deliverable: Provide assigned staff to support the design, development, implementation, and enhancement of reports. Provide an Information System that includes at a minimum:

1. Cost savings.

1. Report or identification of unusual practices by treating providers.

1. Proposed fee schedule revisions and actual cost savings.

1. Comparative analysis of billed amount to paid amount.

1. Produce hard copy and/or electronic format.

1. Electronic transmission of reports to VA.

1. Prepare non-standard reports if requested.

Task 7: Contractor Case Files Maintenance

7a Deliverable: Upon completion of the contract, all computer and paper files and records will be turned over to VA or destroyed at the direction of the VA COR.

Task 8: Help Desk

The Contractor shall provide dedicated and security-cleared customer service representatives for VA job-injured employees to access 24/7 to enroll in the PBM, provide information regarding network pharmacies, claim denials, claim, drug information, payments, and request authorizations for services via the Affiliated Computer Services (ACS), or other related portal.

8. INFORMATION SECURITY

The Contractor and its personnel shall be subject to the same Federal laws, regulations, standards, and VA policies as VA personnel regarding information and information system security. These include, but are not limited to, Federal Information Security Management Act (FISMA), Appendix III of the Office of Management and Budget Circular A-130, and guidance and standards available from the Department of Commerce's National Institute of Standards & Technology (NIST). This also includes the use of common security configurations available from NIST's web site at http://checklists.nist.gov. To ensure that appropriate security controls are in place.

All information and material concerning Federal Workers’ Compensation claims or data that the Contractor may acquire as a result of providing PBM services to VA, whether such claims or data are electronic, verbal or written, are covered by the Privacy Act System of Records (DOL/GOVT-1) and remain the property of DOL. The contractor must comply with all DOL rules and procedures regarding the protection of records in the DOL/GOVT-1 Privacy Act System of Records as published in the Federal Register. All information and material received from VA regarding claims or data shall be stored and maintained in the Contractor’s secured system, separate from any other agency or company information.

The contractor shall not disclose, sell, market or utilize any information and material concerning Federal Workers’ Compensation they acquire as a result of providing PBM services to the VA for any other purposes that are not explicitly included in this contract.

For any data not governed by the preceding two paragraphs, the contractor must also follow the procedures set forth in Section C.1 “VA Information and Information System Security/Privacy Requirements for IT Contracts”.

9. APPLICABLE DOCUMENTATION, DEFINITIONS

All Contractor personnel shall follow and adhere to all the policies and procedures established by OWCP DOL Office of WC Programs for the Federal WC Program and Office of Occupational Safety and Health for the Federal OSH Program, contained in their regulations, in FECA, OSHA and in the Privacy Act. All technical terms used in this contract are as defined by DOL in its regulations or in the FECA and OSHA legislation. http://www.dol.gov/owcp/dfec/procedure-manual.htm

10. DELIVERABLE SCHEDULE

Coordination and Facilitation of Kick-Off Meeting and Meeting Agenda

Work Plan

Progress Reports

Periodic Information on Cost Savings

11. KEY PERSONNEL

The Contractor shall assign sufficient experienced personnel who are qualified in the conduct of similar skills and who have a proven background and level of experience for the work required. Key project personnel include only those persons who will be assigned to this project and who will be the actual personnel responsible for management and performance in the event the proposal results in award. The contractor shall provide a full-time Program/Project manager to provide support the VA account; this PM must have at least five years' experience managing a PBM program. The Contractor shall designate a minimum of one other individual as key personnel, such as a clinical director, a head of reporting team, or VP which the Contractor deems essential to contract performance.

12. SUBSTITUTION OF KEY PERSONNEL

All Contractor requests for approval of substitutions hereunder shall be submitted in writing to the COR, and the CO at least 15 calendar days in advance of the effective date, whenever possible, and shall provide a detailed explanation of the circumstances necessitating the proposed substitution, a complete resume for the proposed substitute, and any other information requested by the CO necessary to approve or disapprove the proposed substitution. The résumés shall include the employee's education (including names of school and degree/certificate), specific experiences that are directly related to the requirements of this procurement, periods of employment, title and job descriptions, and level of responsibility. New personnel shall not commence work until all necessary security requirements have been fulfilled and resumes provided and accepted. The COR, and the CO will evaluate such requests and promptly notify the Contractor of approval or disapproval in writing. Any substituted personnel shall have the equivalent or better education, experience, and credentials than the personnel they may replace, subject to VA review and approval.

13. CONTRACTOR PERSONNEL

The Contractor shall be responsible for managing and overseeing the activities of all Contractor personnel, as well as sub-Contractor (if any) efforts used in performance of this effort. The Contractor's management responsibilities shall include all activities necessary to ensure the accomplishment of timely and effective support, performed in accordance with the requirements contained in the statement of work.

The CO, in consultation with the COR, will approve any request to substitute personnel to be used in conducting the review. Any proposed substitution shall be of personnel at comparable backgrounds as the person being replaced.

The CO may notify the Contractor and request immediate removal of any personnel assigned to the task order by the Contractor that are deemed to have a conflict of interest with the government or if the performance is deemed to be unsatisfactory. The reason for removal shall be documented and replacement personnel shall be identified within three business days of the notification. Employment and staffing difficulties shall not be justification for failure to meet established schedules.

SECTION D - CONTRACT DOCUMENTS, EXHIBITS, OR ATTACHMENTS

See attached documents:

D.2 ATTACHMENT B: PRICE MODEL_REV.1

D.3 ATTACHMENT C: CASE MANAGEMENT PRICE MODEL

D.4…