36C79123R0007 9-05-23 final.docx

36C79123R0007

PAGE 1 OF

1. REQUISITION NO.

2. CONTRACT NO.

3. AWARD/EFFECTIVE DATE

4. ORDER NO.

5. SOLICITATION NUMBER

6. SOLICITATION ISSUE DATE

a. NAME

b. TELEPHONE NO. (No Collect Calls)

8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY

CODE

10. THIS ACQUISITION IS

UNRESTRICTED OR

SET ASIDE:

% FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ

IFB

RFP

15. DELIVER TO

CODE

16. ADMINISTERED BY

CODE

17a. CONTRACTOR/OFFEROR

CODE

FACILITY CODE

18a. PAYMENT WILL BE MADE BY

CODE

TELEPHONE NO.

UEI:

EFT:

PHONE:

FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19.

20.

21.

22.

23.

24.

ITEM NO.

SCHEDULE OF SUPPLIES/SERVICES

QUANTITY

UNIT

UNIT PRICE

AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

26. TOTAL AWARD AMOUNT (For Govt. Use Only) 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________

29. AWARD OF CONTRACT: REF. ___________________________________ OFFER

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

DATED ________________________________. YOUR OFFER ON SOLICITATION

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED

SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER) 30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION

(REV. NOV 2021)

PREVIOUS EDITION IS NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL PRODUCTS AND COMMERCIAL SERVICES

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

09-05-2023 Sandra McAnany (303)-215-5246 10-05-2023

12:00 PM

MDT

Department of Veterans Affairs Commodities & Services Acquisition Svc (003B6E) 555 Corporate Circle Golden CO 80401-5621

X

524292 $45.5 Million

N/A

Department of Veterans Affairs Veteran Family Member Programs Ptarmigan at Cherry Creek 3733 Cherry Creek North Dr, Ste 450 Denver CO 80209t

Department of Veterans Affairs Commodities & Services Acquisition Svc (003B6E) 555 Corporate Circle Golden CO 80401-5621

Electronic Payment Requests Submit Invoices at:

http://www.fsc.va.gov/einvoice.asp

Contractor is to provide Pharmacy Benefit Management Services for Veteran Family Member Programs.

Period of Performance is 4/1/2024 to 3/31/2025, with four additional one-year options to continue services through 3/31/2029.

Complete page 4 Contract Administration Data.

See Attachment 12 for Contract Pricing Schedule.

See Performance Work Statement, page 11.

All questions from offeror regarding the solicitation shall be submitted on or before 12:00 pm MT on 09/09/2023.

Sandra McAnany Contracting Officer

Table of Contents

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

1.CONTRACT ADMINISTRATION MATTERS WILL BE HANDLED BY:

Contractor’s Name/Address/City-State-Zip (please print or type):

Point of Contact/Title:

Telephone Number:

Fax Number:

Email:

Contractor Unique Entity Identification (UEI):

Federal Taxpayer Identification Number:

Contractor’s Contractor Performance Assessment Reporting System (CPARS) Point of Contact:

Name & Title:

Telephone Number:

Email:

Government:

Contracting Officer: Sandra McAnany, sandra.mcanany@va.gov, 303-215-5246 Contract Specialist: Joanna Hudson-Lundquist, joanna.hudson-lundquist@va.gov, 303-273-6225 Department of Veterans Affairs Commodities & Services Acquisition Service 555 Corporate Circle Golden, CO 80401

2.CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with Federal Acquisition Regulation (FAR) Clause 52.232-33, Payment by Electronic Funds Transfer—System for Award Management.

3. CLAIMS REIMBURSEMENT:

Please see Performance Work Statement, Section 4.6.

4. POST AWARD ORIENTATION:

Post Award Orientation: The Contracting Officer will schedule a post award orientation for contract orientation purposes.

5. ACKNOWLEDGEMENT OF AMENDMENTS:

The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

“End of Contract Administration Data”

B.2 SCHEDULE OF SERVICES

The VA attempts to be as accurate as possible when providing estimated quantities; however, actual quantities may vary from quantities listed in the Schedule of Services below. The Government’s guaranteed minimum to be ordered during the base year in which the contract is awarded is $50,000.00. The Government’s ceiling amount of this contract is $5,000,000,000.00.

Please complete Attachment 12 Pricing Worksheet and enter the calculated pricing into the table below:

Table 1: Schedule of Services

Base Year: 4/1/2024 to 3/31/2025

Option Year One: 4/1/2025 to 3/31/2026

Option Year Two: 4/1/2026 to 3/31/2027

Option Year Three: 4/1/2027 to 3/31/2028

Option Year Four: 4/1/2028 to 3/31/2029

Gtand Total

* The Administration Total (Administration Fee, Transaction Fee, and Drug Utilization Review Fee) will be invoiced under the contract.

** Dispensing Fee and Drug Costs will be invoiced separately via VFMP claims processing system. Adjudicated claims for Dispensing Fee and discounted Drug Cost will be paid by Electronic Funds Transfer (EFT) by the Treasury.

INSTRUCTIONS TO OFFERORS: A. Offerors shall complete the Solicitation Attachment 12, Pricing Worksheet in its entirety. Proposed pricing for line items (LINs) 0001-0009 shall be entered in Table 1: Schedule of Services, Column E "Unit Price". Column F "Total Price" will populate automatically.

B. Offerors Proposed Estimated Unit Cost of Drugs (before discount) shall be entered in Table 2: Drug Cost Discounts, Column E. Offerors Proposed Discount (% off Average Wholesale Price_ for Specialty

Brand, and Generic Type of Medicine shall be entered in Table 2: Drug Cost Discounts, Column F. Columns E "Unit Price" and Column F "Total Price" in Table 1: Schedule of Services will populate automatically.

The proposed dicount in Table 2, column F will be used for evaluating the drug cost portion of pricing.

Table 2: Drug Cost Discounts

Page 1 of Page 1 of

B.3 PERFORMANCE WORK STATEMENT

Pharmacy Benefit Management (PBM) Services

1. INTRODUCTION:

The Veterans Health Administration (VHA) Office of Integrated Veteran Care (IVC), Veteran Family Member Program (VFMP), processes pharmacy transactions for a variety of health benefit programs administered by the Department of Veterans Affairs (VA). The programs covered include Civilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) 38 CFR, Section 17.270 to 17.278 to include the Caregiver Program, Spina Bifida and Children of Women Vietnam Veterans (CWVV) programs 38 CFR, Section 17.900 to 17.905. VFMP adjudicates pharmacy transactions via Health Insurance Portability and Accountability Act of 1996 (Public Law 104-191) (HIPAA) Compliant Electronic Data Interchange (EDI). VFMP intends to utilize the expertise of a Pharmacy Benefit Manager (PBM) Contractor, with an extensive nationwide network of retail pharmacies. VFMP has historically relied on contract services for real time electronic processing of pharmacy transactions. In procuring these services, VFMP will adjudicate and determine final payment for all eligible pharmacy transactions. VFMP will be adding Camp Lejeune Family Member Program (CLFMP) 38 CFR 3.307 to its family member programs in fiscal year (FY) 24.

The actual prescription activity from FY22 for current VFMP retail pharmacy claims was 5,258,048 prescriptions for approximately 329,300 active VFMP pharmacy users. The actual prescription activity from FY22 for current CLFMP claims was 3,042 prescriptions for approximately 180 family members. An average 3% yearly growth rate for claims projects 5,996,383 claims for FY23.

Program Background:

CHAMPVA: Developed for dependents of permanently and totally disabled veterans, veterans who died from service-connected conditions, or who at the time of death, were rated permanently and totally disabled from a service-connected disability.

Caregiver: Established under the Caregivers and Veterans Omnibus Health Services Act of 2010. The Veterans who meet specific eligibility criteria may receive a primary and secondary caregiver. The Caregiver program offers access to CHAMPVA health care for an in-home designated Veteran caregiver who is not already entitled to care or services under another health care plan.

Spina Bifida: Developed for children of Korea and Vietnam Veterans’ who have been diagnosed with spina bifida.

Children of Women Vietnam Veterans: Developed for children of women Vietnam Veterans who have been determined to have a covered birth defect. Not a comprehensive health care plan; only covers services necessary for the treatment of a covered birth defect and associated medical conditions as determined by Veterans Benefit Administration (VBA).

Camp Lejeune: Developed for family members of Veterans that lived or served at U. S. Marine Corps Base Camp Lejeune, North Carolina, between August 1, 1953, and December 31, 1987, and were potentially exposed to drinking water contaminated with industrial solvents, benzene, and other chemicals. VA must reimburse eligible family members for health care costs related to one or more of 15 specific illnesses or medical conditions sanctioned by law. Those conditions are bladder, breast, kidney, lung and/or esophageal cancer, female infertility, hepatic steatosis, leukemia, miscarriage, multiple myeloma, myelodysplastic syndromes, neurobehavioral effects, non-Hodgkin’s lymphoma, renal toxicity, and scleroderma.

The Camp Lejeune family member programs cover prescriptions filled and/or submitted electronically from retail pharmacies at mail order (VA Meds by Mail (MbM)), on paper by beneficiaries, and electronically from the CHAMPVA In-house Treatment Initiative (CITI) VA Medical Center pharmacies. Claims from VA MbM and paper claims (receipts) for cash services from retail pharmacies submitted by beneficiaries will continue to be processed internally and not through the Contractor.

VFMP currently utilizes an open formulary with some medication exclusions. Medicare eligible CHAMPVA beneficiaries may opt to purchase a Medicare Part D plan. In such case, CHAMPVA is a secondary payer to Medicare, which allows enrolled Contractor network pharmacies to bill VFMP as a secondary payer (electronically through PBM).

2. PROGRAM OBJECTIVES:

Contractor Responsibilities:

A. Provide retail pharmacy services to the government and beneficiaries in the most cost-efficient manner by achieving cost savings, in accordance with the highest standards of retail pharmacy practice.

B. Maximize patient safety.

C. Receive pharmacy claims data from retail pharmacies in the HIPAA designated electronic format.

D. Provide a comprehensive retail pharmacy network to all eligible VFMP beneficiaries living in the fifty United States, the District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, the Northern Mariana Islands, the American Samoa, and the Minor Outlying Islands.

E. Provide a conduit for on-line coordination of benefits from other primary payers.

F. Achieve the highest level of beneficiary satisfaction possible through the provision of friendly, best quality, and professional retail pharmacy services.

G. Provide VFMP National Council for Prescription Drug Programs (NCPDP) compliant batch files containing electronic claims and reversals that are submitted for processing by retail pharmacies on a regularly scheduled basis.

H. Provide VFMP with detailed reports of pharmacy claims history.

I. Establish and maintain weekly communication between VFMP, Contractor, and other appropriate parties.

3. GENERAL REQUIREMENTS:

VFMP requires a PBM to represent pharmacies throughout the fifty United States, District of Columbia, Puerto Rico, Guam, the U.S. Virgin Islands, the Northern Mariana Islands, the American Samoa, and the Minor Outlying Islands that provides services to CHAMPVA (38 CFR, Section 17.270 to 17.278) to include the Caregiver Program, Spina Bifida, CWVV (38 CFR, Section 17.900 to 17.905) and Camp Lejeune (38 CFR 3.307) which will be added to its family member programs in FY24. The Contractor and its network pharmacy providers agree to abide by the rules, regulations, and procedures governing the various programs administered by VFMP and in accordance with applicable Federal and State laws. Policies for each of these family member programs, as they relate to pharmacy coverage, are available for review at the VA website http://www.va.gov/communitycare.

The Contractor (prime) must supply proof of PBM accreditation through Utilization Review Accreditation Commission (URAC). The Pharmacy Benefit Manager Accreditation with URAC ensures that pharmacy benefit management organizations are committed to consumer protection and transparency and adhere to the Pharmacy and Therapeutics (P&T) Committee standards. The Gold Star Accreditations and Certifications - URAC is common in the pharmacy management industry and is required by IVC to ensure beneficiaries the highest standard of services.

A. Contractor Requirements: Claims accepted at the point of sale by the Contractors nationwide network providers does not guarantee payment of the claim. The Contractor will send VFMP daily NCPDP batch files of claims transmitted from pharmacies daily (as described in Paragraph 4.4 Claims Submission to the Contractor by Network Pharmacy Provider, below).

B. VFMP performs final adjudication and determines payment for all eligible claims. The Contractor is not authorized or responsible for any adjudication of claims. All claims rejected by VFMP will NOT be paid to the Contractor. VFMP rejects approximately 0.05% of claims upon receipt annually, usually due to changes in eligibility. The Contractor has the right to seek compensation from the responsible party for all VFMP rejected claims.

C. The Contractor provides all labor, materials, equipment, transportation, and supervision necessary to complete the requirements in this Performance Work Statement (PWS) in accordance with the highest level of quality standards and aligned with accepted industry best practices through URAC PBM defined standards and accreditation. Under no circumstances and in no way will the Contractor act as a representative of VFMP.

D. It is expressly agreed and understood that the pharmaceutical services provided by pharmacies represented by the Contractor are rendered in their capacity as autonomous pharmacies. VFMP retains no control or supervision over the professional aspects of the pharmaceutical services of these pharmacies.

E. The Contractor shall accept from VFMP a minimum of four daily files to include the Eligibility File (proprietary format or X12 834), the Claims Response File (proprietary or NCPDP batch format), the Reversal Response File (proprietary or NCPDP batch format), and the Secondary response (proprietary or X12 835). See Attachment 1 – Eligibility, Primary Status, Secondary Response, Reversal, and Reversal Response Formats for proprietary file information. The daily Eligibility File contains eligible beneficiaries within each program and will be loaded into the Contractors beneficiary eligibility database no later than 4 am Eastern Standard Time (EST) when available from the Government by 2 am EST. This data is not a guarantee of coverage or payment. Final determination of eligibility, coverage, and payment are made at the time of claims adjudication by VFMP.

F. The Contractor will submit up to six separate batch files daily, to include but not limited to the following: Coordination of Benefits (COB) (where VFMP is secondary) Claims, COB Reversal, CITI Claims, CITI Reversals, Standard Retail (where VFMP is primary) Benefit Claims File, and Standard Retail Benefit Reversal File. Medicaid Subrogation 3.0 Claims and Medicaid Subrogation 3.0 Reversals may be requested at a later agreed upon date. Files will be submitted to VFMP by 4 am EST.

G. The CHAMPVA beneficiary deductible is a combined medical and pharmacy deductible. The Contractor will receive and process, along with beneficiary information, the deductible remaining (accumulator) information provided by VFMP as outlined in the Specific Requirements, Paragraph 4.1 Beneficiary Cost Share. All VFMP programs have a unique identifier for each person on the eligibility file that is transmitted daily.

H. VFMP beneficiaries have a unique program authorization card, with name and ID number (printed as “Beneficiary SSN” on the front) issued from VFMP. The Contractor will provide a Pharmacy ID card to identified eligible beneficiaries for use within the pharmacy network. The Contractor supplied Pharmacy ID card will comply with NCPDP standards and instructions from VFMP. The Contractor will provide all ID cards to beneficiaries within seven days of receipt of request (includes new cards, lost card, and eligibility status change).

I. The use of any VFMP logos and all marketing information provided by the Contractor to network pharmacies or VFMP beneficiaries must be approved by VFMP prior to distribution.

J. The Contractor will provide a dedicated testing environment, separate from production and development environments, to support testing activities. This test environment should mirror the production environment as much as possible, with data refreshed in the environment on at least a biannual basis. VA users who conduct testing activities will receive access to this testing environment. The Contractor and/or the network provider will not assess any fees or charges to VFMP for testing; this includes all implementation and/or transmission of claims for testing purposes. All data transmission expenses associated with submitting and receiving test data under the awarded contract shall be borne by the Contractor and/or its pharmacy providers. All VFMP equipment or software costs required for new initiatives or required by regulation for VFMP to process claims from the Contractor will be paid by VFMP.

K. The Contractor will ensure, by way of online real time adjudication edits, that all claims submitted to VFMP do not include any excluded prescription drugs, medical supplies, or devices. See Attachment 3 – Excluded Items. The submission of an electronic claim by the Contractor is a claim for payment and intentional misrepresentation or falsification of any record or other information essential to that claim is subject to prosecution under federal criminal and civil laws and, upon conviction, may result in fines and/or imprisonment. For more information, see the False Claims Act [31 U.S.C § § 3729-3733].

L. The Contractor and pharmacy provider will inquire of the beneficiary about Other Health Insurance (OHI) status and incorporate OHI information into their point-of-sale adjudication process in accordance with program requirements. Identifiers exist on VFMP eligibility file that denote the beneficiary health plan (CHAMPVA, Spina Bifida, CWVV or Camp Lejeune) and OHI coverage.

M. The Contractor will perform Drug Utilization Review (DUR) of all pharmacy claims processed in their system.

N. The Contractor will have the necessary personnel to authorize overrides to rejected claims from network pharmacies. The Contractor is given specific authority to override edits in certain instances for vacation supplies, lost medications, and other instances as determined by VFMP. See Attachment 2 – Override Procedures for the process that is followed when a beneficiary is requesting an early fill and a list of items that require approval from VFMP prior to dispensing.

O. Claims for medical supplies (non-drug items), which have National Drug Codes (NDC), may be submitted by the network pharmacies to the Contractor using NCPDP telecommunication standards as established by HIPAA rules. See Attachment 3 – Excluded Items for a list of non-covered items. The official list will be provided at contract award.

4. SPECIFIC REQUIREMENTS:

4.1 Beneficiary Cost Share:

A. CHAMPVA (to include the Caregiver):

i. The Contractor calculates the beneficiary cost share at the time of service. The cost share is always twenty-five percent (25%) of the VFMP allowable amount, after the individual/family deductible ($50 individual/$100 family) has been met until such time as the catastrophic cap of $3,000 has been met for that benefit (calendar) year. The provider will collect the deductible when applicable. Once the catastrophic cap has been met for the benefit year, VFMP reimburses at 100% of the allowable amount. The billed charge submitted to VFMP is the actual amount billed plus any applicable dispensing fee. The beneficiary cost share is never to be calculated on an amount different than what is billed to VFMP.

ii. The Contractor calculates the beneficiary cost share for coordination of benefit claims from Other Health Insurance Plans from VFMP. VFMP reimburses 100% of the primary payers cost share for covered benefits.

iii. There will be no beneficiary cost share, deductible, or catastrophic cap for CITI eligible beneficiaries. The Contractor will not pay the CITI pharmacies as this will be done via funds transfer by VFMP.

B. Spina Bifida/CWVV:

i. There is no deductible or cost-share for Spina Bifida or CWVV beneficiaries. The Contractor will ensure that the necessary program claim edits are in place for the provider to collect no monies from Spina Bifida or CWVV beneficiaries.

C. Camp Lejeune:

i. There is no deductible or cost-share for Camp Lejeune beneficiaries. The Contractor will ensure that the necessary program claim edits are in place for the provider to collect no monies from Camp Lejeune beneficiaries.

4.2 Pharmacy Network Access:

A. The Contractor will create and maintain a pharmacy network sufficient to meet the following minimum beneficiary access standards on an overall basis:

i. Urban: a pharmacy within two miles estimated driving distance of 90% of the beneficiaries;

ii. Suburban: a pharmacy within five miles estimated driving distance of 90% of the beneficiaries;

iii. Rural: a pharmacy within fifteen miles estimated driving distance of 90% of the beneficiaries.

An Excel spreadsheet showing the distribution of utilizing VFMP enrollees by zip code is provided as Attachment 4 – FY22 Zip Codes.

B. The Contractor will ensure that the number of pharmacies included in its network does not decrease by more than 10% of the total number of pharmacies originally proposed for its network during the life of the contract.

4.3 Pharmacy Network Services:

A. The Contractor will establish and maintain a pharmacy network throughout the fifty (50) United States, the District of Columbia, Puerto Rico, Guam, the Northern Mariana Islands, the U.S. Virgin Islands, the American Samoa, and the Minor Outlying Islands.

B. All network pharmacies must be fully licensed and certified in accordance with applicable Federal and State laws and credentialed according to the Contractors criteria. This information must be made available to VFMP upon request.

C. The Contractor must provide technical assistance to network pharmacies through the Contractors pharmacy help desk.

D. The Contractor must coordinate with the VFMP COR for inquiries that require VFMP input.

E. The Contractor must require network pharmacies to maintain a process to document the receipt of medication by a VFMP beneficiary or the beneficiary’s authorized agent and meet HIPAA requirements and standards.

F. The Contractor must ensure that network pharmacies collect beneficiary cost share amounts up front as returned on the electronic claim’s response. The Contractor ensure payer sheets and provider manuals are available to each participating pharmacy provider. The Contractor will review, update, and disseminate payer sheets and provider manuals any time there are substantive changes to VFMP program requirements or the contract. The provider manual and all updates to the payer sheet require VFMP approval prior to distribution.

G. VFMP requires the Contractor to support the current NCPDP telecommunication standard for transmission of electronic prescribing functionality throughout the network of retail pharmacies to improve the safety and accuracy of the prescribing process. The Contractor must be able to adjudicate claims utilizing electronic prescribing capabilities in the allowable NCPDP SCRIPT standard for the secure, electronic transmission of prescriptions and prescription related information. These capabilities must allow an eligible prescriber to select medications, print prescriptions, transmit prescriptions electronically, and receive safety alerts. These alerts must include automated prompts that offer information on the drug being prescribed and warn the prescriber of possible undesirable or unsafe situations regarding current and profile medications, such as potential drug-drug interactions, duplicate therapies, and dosing warnings/cautions.

4.4 Claims Submission to the Contractor by Network Pharmacy Provider:

A. The Contractor will ensure, at its own expense, that electronic claims are submitted online, in real time, utilizing HIPAA designated standards.

B. The Contractor will ensure that network pharmacies submit claims for processing within one year of the date of service. Claims received after one year from date of service that fail to meet the timely filing deadline requirements will be denied by VFMP. The CHAMPVA Operational Policy Manual Section 1.1, II. Operational Policy, B. Timely Filing link provides additional policy specifics.

C. The Contractor must accept and process all electronic claims received from network pharmacies for pharmaceuticals and supplies furnished in the fifty (50) United States, the District of Columbia, Puerto Rico, Guam, the Northern Mariana Islands, the U.S. Virgin Islands, the American Samoa, and the Minor Outlying Islands.

D. The Contractor must ensure that reversals from network pharmacies are sent timely. VFMP expects reversals be completed within seven (7) calendar days. Reversals submitted to the Contractor within one (1) year from the date of service will be accepted by VFMP.

E. The Contractor must ensure that each claim passes administrative and plan edits established according to VFMP policy. The current policy manuals for VFMP programs are available online at http://www.va.gov/communitycare.

F. Modification to the claim edits or other electronic media claim procedures must be submitted in writing to the Contractor by VFMP. The Contractor will be provided time to make any necessary system changes to accommodate such modifications; however, since the time required is dependent on the complexity of any change, the Contractor and VFMP will negotiate and agree in writing to reasonable timelines prior to each change.

G. The Contractor will submit up to six separate NCPDP batch files daily to include but not limited to the following: Standard Business (where VFMP is primary) Billing and Reversal, CITI Billing and Reversal, and Coordination of Benefit (COB) (where VFMP is secondary) Billing and Reversal. Medicaid Subrogation (3.0) Billing and Reversal may be requested at a later agreed upon date. Files will be submitted by 6 am EST. The Contractor will be advised of all discrepancies via NCPDP batch or proprietary response files from VFMP.

H. Claim (billing) files will be submitted daily, in batch, to VFMP with a 1-day lag.

I. The Contractor is required to provide VFMP medical documentation from the medical provider/prescriber for medications listed in Attachment 2 – Override Procedures prior to payment of the claim until such time VFMP can accept electronic documentation.

J. VFMP will apply validity and consistency edits to all submissions by the Contractor. VFMP will accept all valid claims which meet such edit requirements and return errant submissions for correction. The Contractor will research and correct all discrepant claim submissions. Claims rejected for compliance prior to VFMP’s adjudication will be corrected by the Contractor and resubmitted electronically as new claims. (If the Contractor receives a claim on a Secondary Response file or X12 835, this means that the claim has already passed through VFMP’s adjudication system.)

K. When the time frames for transmission of claims by the Contractor cannot be met, the COR will be notified by phone and/or e-mail of the failure to meet the time frame, reason(s) why, and estimated time to resumption of transmissions.

4.5 Claims Submission by VA Facilities:

A. The Contractor will receive electronic CITI claims from participating VA facilities via an established network and make real-time coverage and eligibility determinations.

B. The Contractor will return eligibility and coverage determinations on CITI claims to the requesting VA Facility through the established network.

4.6 Claim Reimbursements:

A. Claim reimbursements for network claims will be made to the Contractor via Electronic Funds Transfer (EFT) from the U.S. Treasury daily on claims that have been determined to meet all criteria for reimbursement by VFMP. The Contractor, on behalf of pharmacy providers, will accept consolidated payments for all reimbursements to the same corporate tax identification number. A Secondary Response or an X12 835 file with remittance information will be returned to the Contractor.

B. The allowable amounts for network claims submitted to VFMP will be based on the pricing proposal and discounts submitted in VFMP network in the reimbursement pricing table. Per CHAMPVA Operational Policy Manual Chapter 3, Section 5.11, Title: Pharmacy Reimbursement, the prescription dispensing fee shall not exceed $3.00. The CHAMPVA Operational Policy Manual Section 5.11 Pharmacy Reimbursement link provides additional policy specifics.

C. Reimbursement to the Contractor for prescriptions and medical supplies for the CHAMPVA program, to include eligible Caregivers, will be seventy-five percent (75%) of the allowable amount after the individual/family deductible (currently $50 individual and $100 family) has been met, until such time as the catastrophic cap of $3,000 has been met for that benefit year, at which time VFMP reimburses at 100% of the allowable amount. Reimbursement for the Spina Bifida, Camp Lejeune, and CWVV programs will be 100% of the allowable amount.

D. The Contractor shall submit a daily file identifying CITI claims to be paid by VFMP. VFMP will pay the participating VA facilities directly.

4.7 Claims Processing Standards between the Pharmacy and the Contractor:

A. Ninety-nine percent (99%) of electronic claims will be processed to completion within five seconds of receipt, measured monthly. By the 8th day of each month, the Contractor will provide reports to VFMP detailing processing times for the previous month.

B. Scheduled downtime from processing of claims must not exceed eight hours during any month. The Contractor will provide a schedule of planned outages. Planned outages must be scheduled after Midnight Eastern Time and systems must be operational by 6 AM Eastern Time. By the 8th day of each month, the Contractor will provide a report detailing actual outages.

C. When an unscheduled outage occurs, the Contractor will notify the VFMP program office immediately and provide hourly updates of progress and estimated time for restoration of services by phone and e-mail.

4.8 Claim Reversal Submission to VFMP:

A. The Contractor will transmit one NCPDP reversal batch of an unlimited number of prescriptions claim records daily and assume responsibility for ensuring that all reversals submitted to VFMP contain complete information.

B. The Contractor will be advised on the reversal response file of the amount due for all accepted network reversal transactions by VFMP.

C. The Contractor will submit reversal payment to https://www.pay.gov twice monthly with an Excel spreadsheet attachment for reconciliation purposes.

4.9 Beneficiary Refunds:

A. If VFMP determines a refund is due, VFMP will initiate and ensure that the refund is properly made. If the Contractor determines a refund is due, the Contractor will identify the refund situation to VFMP prior to taking any action. The Contractor will send a written report to VFMP of all identified refund situations on or before the 28th of every month. VFMP has the right to audit files that are relevant to the refund situation.

4.10 Recoupments:

A. If VFMP identifies, after a claim has been processed and paid to the Contractor, that a change in eligibility occurred, VFMP will generate a recoupment action.

B. The Contractor will provide all recoupment payments to https://www.pay.gov on behalf of its pharmacy providers. VFMP’s recoupment action will contain a detailed payment account on each claim by provider. Recoupment payments will be made within 30 calendar days of the date on the Bill of Collection to avoid penalties, interest, and fees.

C. The Contractor will make a reasonable effort to identify possible recoupment situations and advise VFMP of such situations. VFMP has the right to audit files that are relevant to the recoupment situation. VFMP will review each case and advise the Contractor of the results.

D. If it is determined the money is due from the beneficiary, the Contractor may initiate a recoupment action from the beneficiary when VFMP deems it is appropriate.

E. Under no circumstances will a beneficiary be billed a billing fee or imposed on any additional charge over and above the VFMP determined allowable amount.

Ref: Attachment 5 – Adjudication and Recoupment Process Maps provides process maps detailing the adjudication and recoupment process.

4.11 Rebates:

A. VFMP recognizes that there may be rebates offered to the Contractor for claims processed under this requirement. VFMP will allow the Contractor to obtain manufacturer pharmaceutical rebates through the administration of this program while sharing the benefit of these rebates with VFMP. The Contractor shall propose the optimal rebate solution and specify how it will be shared with VFMP. The sharing of these rebates should be shown in the pricing table as percentages off the drug pricing. Ref: Attachment 6 – FY22 NDC Listing provides all NDC’s processed in the previous fiscal year.

4.12 Beneficiary Help Desk:

A. The Contractor will maintain a toll-free Beneficiary Help Desk telephone number at their own expense for use by VFMP beneficiaries to assist with questions regarding pharmacy submitted claims, routine coverage questions, or to determine which providers are located near them. This toll-free number will be staffed, at a minimum, daily from 6 am to midnight Eastern Standard Time (EST).

B. The Contractor may use an Automated Response Unit (ARU) to receive beneficiary calls. If calls are received by an ARU, 98% of all calls will be acknowledged within 10 seconds. The first menu choice available to the caller will allow the caller to be transferred to a Customer Service Representative. Each subsequent menu selection will be answered and transferred within 10 seconds of the menu selection being made, 98% of the time. If the caller requests to speak with a customer service representative, they will be connected within 10 seconds of the request, 98% of the time.

C. The Contractor will ensure the necessary number and type of personnel are available during all hours of operation of the Beneficiary Help Desk to answer beneficiary questions.

D. Telephone Response Standards: When a caller requests to speak with a Customer Service Representative, the connection will be made within 10 seconds, 98% of the time. The abandonment rate will not exceed 2%. The blocked call rate will not exceed 2%. The Contractor will fully resolve (meaning the caller understands the resolution) all customer service calls 95% of the time during the initial call and 100% of the time resolution within two working days of receiving the initial call.

4.13 Pharmacy Help Desk:

A. The Contractor will maintain a toll-free Pharmacy Help Desk telephone number at their own expense for use by the network pharmacies to assist with questions regarding pharmacy submitted claims or routine questions. This toll-free number will be staffed, at a minimum, daily from 6 am to midnight Eastern Standard Time (EST).

B. The Contractor may use an Automated Response Unit (ARU) to receive pharmacy calls. If calls are received by an ARU, 98% of all telephone calls shall be acknowledged within 10 seconds. The first menu choice presented to the caller shall allow the caller to be transferred to a Customer Service Representative. Each subsequent menu selection will be answered and transferred within 10 seconds of the menu selection being made, 98% of the time. If the caller requests to speak with a customer service representative, they will be connected 98% of the time within 30 seconds of the request.

C. The Contractor will ensure the necessary number and type of personnel are available during all hours of operation of the Pharmacy Help Desk to answer questions.

D. Telephone Response Standards: When a caller requests to speak with a Customer Service Representative, the connection will be made within 30 seconds, 98% of the time. The abandonment rate will not exceed 4%. The blocked call rate will not exceed 2%.

4.14 Internet Website:

A. The Contractor will maintain an internet website at its own expense. The website will have the ability to look up network locations by zip codes, print a temporary ID card, and provide VFMP beneficiaries with a telephone number or mailing information for the Contractor and VFMP.

4.15 Access to Claim Data:

A. The Contractor will ensure only authorized access to claim data to guarantee that the electronic data interchange (EDI) messages are authentic, properly authorized, and traceable. The messages will also be protected from loss, modification, or unauthorized access or disclosure both during transmission and storage. Health claim submissions for treatment for sickle cell anemia, Human Immunodeficiency Virus (HIV), and substance and alcohol abuse are specifically protected under 38 U.S.C. § 7332 – Confidentiality of Certain Medical Records. This statute includes a penalty provision for the unauthorized use or disclosure of information. To maintain confidentiality and to preclude the filing of fraudulent clams, access to all claims data will be restricted to:

i. The designated/authorized employees of the Contractor and each of their participating pharmacy providers.

ii. The designated/authorized employees of VFMP, and/or

iii. Any third party as deemed necessary by the Contractor, each participating pharmacy provider, and VFMP.

iv. The Contractor, as a business associate of VFMP under the terms of the contract will comply with all requirements and provisions regarding Privacy, Protected Health Information (PHI) and Security as required by HIPAA.

4.16 Network Certification and Administration:

A. The Contractor will maintain complete provider certification documentation on all providers and make them available for review by VFMP, upon request. Accompanying all new certification documents will be the following provider licensure information.

i. Drug Enforcement Agency (DEA) identification number by pharmacy

ii. State pharmacy license number by pharmacy

iii. NCPDP number ((formerly called (National Association of Boards of Pharmacy) NABP)) of each pharmacy

iv. Internal pharmacy designated number (applies only to pharmacy chains or multi-locations i.e., Store Number)

v. Complete address of each pharmacy including telephone number

vi. Federal tax identification number of each pharmacy/pharmacy chain

vii. Provider’s NPI (National Provider Identifier) from NPPES (National Plan & Provider Enumeration System)

4.17 Databases:

A. The Contractor will ensure that all Contractor reference database files are maintained and updated weekly to include the most recently published information. Those files include, but are not limited to, DEA provider files, MediSpan, First DataBank, Micromedex, NCPDP pharmacy provider file, HCIdea, and the NPI.

B. VFMP utilizes MediSpan® for identifying NDCs and drug pricing.

4.18 Audits:

A. The Contractor will retain the submitted electronic transactions and any other source documentation for a period of no less than 75 months from the date of service.

B. VFMP, or any authorized representative, has the right to conduct an audit during normal business hours at the Contractors site at no cost to the government, and confirm any source documents (such as the prescription form, the NCPDP prescription data captured on-line from the provider, or any documents used to bill VFMP) that are relevant to claims submitted to VFMP electronically. Incorrect payments, which are discovered because of such an audit, will be adjusted in accordance with VA guidelines and applicable program provisions. VFMP may request ad hoc reports (regarding costs, time frames, etc.). The Contractor will provide adequate space and any source documents or reports needed by VFMP to verify compliance at no charge to VFMP.

C. VFMP may request that the Contractor perform audits of certain network pharmacy providers when fraud, abuse, or other aberrant activity is suspected.

D. The Contractor will notify VFMP of any audits performed and any recoupment actions resulting from such audits by the Contractor, which were performed because of the Contractors Quality Assurance Plan.

4.19 Reporting:

A. The Contractor will provide a list of available monthly/periodic reports summarizing claim data and identifying trends, averages, utilization rates and other such information needed to effectively track VFMP expenditures and drug utilization.

B. The reports will include, at a minimum:

i. Total Number of Prescriptions

ii. Total Number of Brand Name Prescriptions

iii. Total Number of Generic Prescriptions

i…