Amendment_0002.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT 1. CONTRACT ID CODE PAGE OF PAGES

1 3

2. AMENDMENT/MODIFICATION NO.

000002

3. EFFECTIVE DATE

08/08/2013

4. REQUISITION/PURCHASE REQ. NO. 5. PROJECT NO. (If applicable)

6. ISSUED BY CODE HT9402 7. ADMINISTERED BY (If other than Item 6) CODE HT9402

DEPARTMENT OF DEFENSE

TRICARE MANAGEMENT ACTIVITY COD-AB

16401 E CENTRETECH PARKWAY

AURORA CO 80011-9066

MATTHEW ANDERSON 3036763754

DEPARTMENT OF DEFENSE

TRICARE MANAGEMENT ACTIVITY COD-AB

16401 E CENTRETECH PARKWAY

AURORA CO 80011-9066

8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP Code) (x) 9A. AMENDMENT OF SOLICITATION NO.

HT9402-13-R-0001

x 9B. DATED (SEE ITEM 11)

06/27/2013

10A. MODIFICATION OF CONTRACT/ORDER NO.

10B. DATED (SEE ITEM 13)

CODE FACILITY CODE

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

x The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers is extended, x is not extended.

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: (a) By completing Items 8 and 15, and returning 2 copies of the amendment; (b) By acknowledging receipt of this amendment on each copy of the offer submitted; or (c) By separate letter or telegram which includes a reference to the solicitation and amendment numbers. FAILURE OF YOUR ACKNOWLEDGEMENT TO BE RECEIVED AT THE PLACE DESIGNATED FOR THE RECEIPT OF OFFERS PRIOR TO THE HOUR AND DATE SPECIFIED MAY 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 telegram or letter, provided each telegram or letter makes reference to the solicitation and this amendment, and is received prior to the opening hour and date specified.

12. ACCOUNTING AND APPROPRIATION DATA (If required)

13. THIS ITEM ONLY APPLIES TO MODIFICATION OF CONTRACTS/ORDERS. IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

CHECK ONE

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.

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

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

D. OTHER (Specify type of modification and authority)

E. IMPORTANT: Contractor is not, is required to sign this document and return copies to the issuing office.

14. DESCRIPTION OF AMENDMENT/MODIFICATION (Organized by UCF section headings, including solicitation/contract subject matter where feasible.)

A. The purpose of this Amendment 0002 is to revise Section C, DESCRIPTION/SPECIFICATION /STATEMENT OF WORK; Section H, SPECIAL CONTRACT REQUIREMENTS; Section L, INSTRUCTIONS, CONDITIONS AND NOTICES TO OFFERORS; Section M, EVALUATION FACTORS FOR AWARD; Exhibit L-7, DRAFT HIGH COST DRUG MEDICATION LIST; and Exhibit L-10, HISTORICAL DATA AND OTHER

INFORMATION AVAILABLE TO OFFERORS

(SEE CONTINUATION SHEET)

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 (Type or print) 16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print) Bruce Mitterer 303.676.3812 bruce.mitterer@tma.osd.mil

15B. CONTRACTOR/OFFEROR

(Signature of person authorized to sign)

15C. DATE SIGNED 16B. UNITED STATES OF AMERICA

(Signature of Contracting Officer)

16C. DATE SIGNED

NSN 7540-01-152-8070

Previous edition unusable

STANDARD FORM 30 (REV. 10-83)

Prescribed by GSA

FAR (48 CFR) 53.243

mailto:bruce.mitterer@tma.osd.mil

AMENDMENT 0002, SOLICITATION HT9402-13-R-0001

B. Section C, DESCRIPTION/SPECIFICATION/STATEMENT OF WORK is revised as follows:

1) Change paragraph C.7.7.2.

FROM: “The Contractor shall provide reporting on the number of transfers requested and completed (CDRL Q140). 100% of all transfers shall be completed within 21 days from beneficiary authorization.”

TO: “The Contractor shall provide reporting on the number of transfers requested and completed (CDRL Q140).”

C. Section H, SPECIAL CONTRACT REQUIREMENTS is revised as follows:

2) Change paragraph H.1.2.

FROM: “The Government will assess a negative incentive if the total actual retail network reimbursement cost in a contract option period exceeds the Total Expected Government Cost for Reimbursement of Retail Network Pharmacy Costs that would have resulted from applying the Guaranteed Average Price Adjustment Percentage and the Guaranteed Average Dispensing Fee per prescription to the prescription transaction processed to completion during the contract option period. The difference between the actual costs and the Total Expected Government Cost for Reimbursement of Retail Network Pharmacy Costs will be a negative incentive assessed for the option period. For example, if in any option period the Contractor's Guaranteed Average Price Adjustment Percentage and the Guaranteed Average Dispensing Fee per prescription result in a Total Expected Government Cost for Reimbursement of Retail Network Pharmacy Costs of $5 billion, and the actual cost to the Government was $5.01 billion, the Contractor would be assessed a negative incentive amount of $10 million (the entire difference) for that option period.”

TO: “In the event the total actual retail network reimbursement cost in a contract option period exceeds the Total Expected Government Cost for Reimbursement of Retail Network Pharmacy Costs that would have resulted from applying the Guaranteed Average Price Adjustment Percentage and the Guaranteed Average Dispensing Fee per prescription to the prescription transaction processed to completion during the contract option period, the difference between the actual costs and the Total Expected Government Cost for Reimbursement of Retail Network Pharmacy Costs will be recouped by the Government for that option period. For example, if in any option period the Contractor's Guaranteed Average Price Adjustment Percentage and the Guaranteed Average Dispensing Fee per prescription result in a Total Expected Government Cost for Reimbursement of Retail Network Pharmacy Costs of $5 billion, and the actual cost to the Government was $5.01 billion, the Government would recoup the amount of $10 million (the entire difference) for that option period from the Contractor.”

D. Section L, INSTRUCTIONS, CONDITIONS AND NOTICES TO OFFERORS is revised as follows:

1) Section L, Paragraph L.10.5.1. Delete the last sentence.

2) Section L, Paragraph L.10.15.1. Change the fifth sentence

FROM: “Offerors shall submit only one completed table L-1 for evaluation.”

TO: “Offerors shall submit only one completed table L-1.”

E. Section M, EVALUATION FACTORS FOR AWARD is revised as follows:

1) Section M, Change the second paragraph at M.3.7.1.

FROM: “The total evaluated price will include consideration of FAR 52.217-8, Option to Extend Services.

The Government will multiply the offered unit price of CLINs 7001-7009, 7011-7014 and 7018-7021 by one-half of the estimated quantity of each respective CLIN, and then add that extended amount to the total evaluated price. The Government will also add one-half of the offered lot price of CLINs 7010 and 7015 to the total evaluated price.”

AMENDMENT 0002, SOLICITATION HT9402-13-R-0001

TO: “The total evaluated price will include consideration of FAR 52.217-8, Option to Extend Services.

The Government will multiply the offered unit price of CLINs 7001-7009, 7011-7014 and 7018-7021 by one-half of the estimated quantity of each respective CLIN, and then add that extended amount to the total evaluated price. The Government will also add one-half of the offered lot price of CLINs 7010 and 7015, and one-half of the total expected Government cost for reimbursement of retail network pharmacy costs from the table at exhibit L-1(g) for option year 7 to the total evaluated price.”

F. Exhibit L-7, DRAFT HIGH COST DRUG MEDICATION LIST is removed and replaced with the attached revised

L-7, DRAFT HIGH COST DRUG MEDICATION LIST.

G. Exhibit L-10, HISTORICAL DATA AND OTHER INFORMATION AVAILABLE TO OFFERORS is revised as follows:

1) Add the following to the list of data packages:

• Data Pkg 18 - Prescription Transfers from Retail to Mail Order

• Data Pkg 19 - Assistance Reporting Tool (ART) Pharmacy Referral Volume

• Data Pkg 20 - Prescription Restriction Program Volume

Sections and exhibits revised by this amendment are attached. All other terms and conditions remain unchanged.

SECTION C

DESCRIPTION / SPECIFICATION / STATEMENT OF WORK

H94002-13-R-0001 29

C.1. Program Description

C.1.1. TRICARE is the Department of Defense (DoD) health care program administered by the

TRICARE Management Activity (TMA) by means of the Military Health System (MHS) for approximately 9.6 million active duty and retired members of the Uniformed Services (the U.S. Army, the

U.S. Navy, the U.S. Air Force, the U.S. Marine Corps, the U. S. Coast Guard, the Commissioned Corps of the Public Health Service and the Commissioned Corps of the National Oceanic and Atmospheric

Administration), their spouses and children, including TRICARE for Life beneficiaries entitled to

Medicare Part A and Part B based on their age, disability and/or end-stage renal disease. Also eligible are

Medal of Honor recipients. The TRICARE Pharmacy Program is authorized under 10 USC 1074g and 32

C.F.R. 199.21.

C.1.2. The mission of the MHS is to enhance DoD readiness and national security by providing health support for the full range of military operations. The MHS must be prepared not only to provide a high quality, cost-effective health care benefit to its eligible members during peacetime, but also must be prepared to support the armed forces during exercises, contingencies, operations other than war, and in wartime. The MHS provides quality medical care through: (1) a network of health care providers and pharmacies in the United States and its territories; and (2) direct care Military Treatment Facilities

(MTFs) – (hospitals, health and dental clinics) in the United States and overseas. While the number and size of direct care facilities has declined in recent years, it remains important that MTFs are optimized in order to maintain the clinical skills of military clinical staff to support medical readiness. The direct care system cannot fully support the total demand for health care services; therefore, TRICARE uses the direct care system as the main delivery system, and through contracts, augments the direct care system through a civilian network of providers and facilities serving its eligible members.

C.1.3. TRICARE provides a world-class pharmacy benefit to all eligible beneficiaries through the integration of state of the art technologies to enhance patient safety, efficiency, and cost-effectiveness.

DoD administers an integrated TRICARE Pharmacy Benefits Program offering pharmacy services through direct care pharmacy services at MTFs located at various military bases, retail network pharmacies, authorized retail non-network pharmacies, or delivery through the TRICARE Home

Delivery/Mail Order Pharmacy (TMOP). Retail network pharmacy services are currently available in all

50 states and the District of Columbia, Guam, Puerto Rico, and the U.S. Virgin Islands.

C.1.4. Features of the pharmacy benefits program include the use of the DoD Uniform Formulary, a tiered cost sharing structure, and a preference for generic over branded products. The DoD formulary is managed by the DoD Pharmacy and Therapeutics (P&T) Committee and lists the pharmaceutical agents, by therapeutic classes, that are authorized as basic program benefits. Prescriptions for selected pharmaceutical agents may be subject to prior authorization or utilization review requirements to assure medical necessity, clinical appropriateness and/or cost-effectiveness. DoD has established tiered cost-sharing by which beneficiaries partially defray costs of administering the pharmacy benefits program.

Cost-sharing amounts differ based on the classification of a pharmaceutical agent as generic, formulary, or non-formulary, in conjunction with the point of service from which the agent is acquired. The mail order and retail portions of this benefit are open to all eligible TRICARE beneficiaries. Eligible beneficiaries need not enroll in order to use the program(s).

C.1.5. The Contractor will perform pharmacy benefits management functions, including the following:

perform claims adjudication, administer a retail pharmacy network, operate TMOP, provide clinical services for specialty pharmaceuticals, process direct member reimbursements for claims filled at retail network and non-network pharmacies, perform clinical reviews and provide beneficiary and pharmacy

H94002-13-R-0001 30 support services. The Contractor shall transmit all claim information to the Pharmacy Data Transaction

Service (PDTS), the Government’s designated data warehouse.

C.1.6. The Contractor will also perform as a fiscal intermediary on behalf of DoD to pay for all authorized pharmaceuticals and supplies dispensed for eligible beneficiaries at retail pharmacies.

Government funds, either appropriated or derived from the Medicare-eligible Retiree Health Care Fund, will be used by the Contractor to pay for all TRICARE prescriptions dispensed by network and non-network retail pharmacies. The Contractor will be paid fees at the contracted rate for performing administrative services under the contract. The fees paid to the Contractor will not be related directly or indirectly to the Government’s acquisition costs of pharmaceuticals under Section 603 of the Veterans

Health Care Act of 1992, or Section 201(a) of the Federal Property and Administrative Services Act of

1949. Upon verification of the patient’s eligibility and acceptance of the TRICARE Encounter Data

(TED) record, the Contractor will forward payment using Government funds to pay for each TRICARE prescription dispensed at retail network pharmacies. Therefore, the Government will be acquiring covered drugs with Government funds for use by the Government.

C.2. Statement of Objectives

The following objectives identify the desired outcomes of this contract and are supported by the technical requirements in Section C:

1. Provide comprehensive pharmacy benefit management services that are efficient, accurate, cost-effective, and maximize patient safety.

2. Provide comprehensive mail order and specialty pharmacy fulfillment services that are efficient, accurate, cost-effective, and maximize patient safety.

3. Provide comprehensive beneficiary education and services that are efficient, accurate, cost-effective, and maximize patient safety and satisfaction.

4. Provide effective management and quality controls and oversight for all services provided.

C.3. Definitions

Definitions specific to this contract, or not otherwise in Appendix B of the TRICARE Operations Manual, are provided in J-1.

C.4. Government-Furnished Information

C.4.1. The Contractor shall connect to the Defense Enrollment Eligibility Reporting System (DEERS), according to the requirements established in the TRICARE Systems Manual.

C.4.2. The Government will provide licenses for the Contractor to access and use DEERS applications, including but not limited to General Inquiry to DEERS (GIQD), Catastrophic Cap and Deductible

Database (CCDD), and Other Health Insurance Standard Insurance Table (OHI/SIT).

H94002-13-R-0001 31

C.4.3. The Government will provide quarterly beneficiary address updates, in accordance with the

Memorandum of Understanding and Data Use Agreement between TMA and the Defense Manpower

Data Center (DMDC).

C.4.4. The Government will provide the Contractor with a Managed Care Pricing File (MCPF), to be used for TMOP replenishment and for adjudicating MTF claims.

C.4.5. The Government will provide a quarterly data file with the names and addresses of newly eligible and newly retired beneficiaries for the Contractor’s use in performing the mailings described under

C.10.4.1.

C.4.6. The Government will provide a quarterly data file for beneficiary mailings related to formulary changes, described under C.10.4.3.

C.4.7. The Government will provide a monthly beneficiary zip code file identifying the number of beneficiaries residing in each zip code, for evaluating and reporting on compliance with network access standards.

C.4.8. The TMA Beneficiary Education & Support Division (BE&S) will design, develop, and print all beneficiary educational materials, including written materials, briefings, and other methods of publicizing the TRICARE benefit, excluding letters and other communication pieces required under this contract.

The Government will provide an electronic portal where printed items can be ordered by the Contractor.

C.4.9. The Government will provide the PDTS Data Dictionary and Data Schema, as described under

C.12.4.2.

C.5. Requirement Documents

C.5.1. Statutory and Regulatory Authority:

o 10 U.S.C. 1074g o 32 C.F.R. 199 o 10 U.S.C. 1086 o 38 U.S.C. 8126

When changes are made to the above statutes or regulations, there will be no change to the contract unless implemented by contract modification.

C.5.2. The following documents are hereby incorporated by reference and made a part of Section C:

o TRICARE Operations Manual (TOM) 6010.56-M dated February 1, 2008, at change 100 o TRICARE Policy Manual (TPM) 6010.57-M dated February 1, 2008, at change 89 o TRICARE Reimbursement Manual (TRM) 6010.58-M dated February 1, 2008, at change o TRICARE Systems Manual (TSM) 7950.2-M dated February 1, 2008 (except DIACAP guidance in Chapter 1, Section 1.1, P3.4 & 3.5.1-3.5.1.7), at change 49

In the event of conflict, the TRICARE Policy Manual shall take precedence over the other three

TRICARE Manuals. The TRICARE Reimbursement Manual shall take precedence over the

TRICARE Systems Manual and the TRICARE Operations Manual. The TRICARE Systems

Manual shall take precedence over the TRICARE Operations Manual.

H94002-13-R-0001 32

C.6. Pharmacy Benefits Management Services

C.6.1. General Claims Processing

C.6.1.1. The Contractor shall provide mail order pharmacy (including specialty pharmacy) services, a retail pharmacy network, claims adjudication for MTF claims and Pharmacy Benefit Management (PBM) services as specified herein. Unless stated otherwise, claims adjudication includes processes outlined in

C.6.1.4 - C.6.1.7 and C.6.1.10, consisting of eligibility check, application of the correct copayment, identification of other health insurance (OHI), benefit design edits, prospective drug utilization review and application of catastrophic cap updates.

C.6.1.2. The Contractor shall accept and process claims submitted by retail network pharmacies, the

TMOP, MTF pharmacies, by beneficiaries for direct reimbursement (including non-network), or as batch files from the Department of Veterans Affairs (DVA) or State Medicaid Agencies.

C.6.1.3. The Contractor shall provide 24 hours a day, 7 days a week claims processing for all locations, excluding downtimes for scheduled maintenance. The Contractor’s claims processing system shall be available no less than 99.5% of the time. The system is considered to be unavailable when the failure rate for claims exceeds 25% for at least 30 minutes. The Contractor shall schedule maintenance windows to coincide or overlap with DEERS maintenance windows, as described in TSM Chapter 3, Section 1.3.

DEERS will attempt to accommodate the Contractor’s needs when establishing a maintenance schedule.

The Contractor shall provide reporting on system availability performance (Contract Data Requirements

List (CDRL M030).

C.6.1.4. The Contractor shall interface with the DEERS to verify eligibility, update the CCDD file, and check for OHI when processing claims for TMOP or retail network pharmacies. The Contractor shall use the applications described in the TOM and TSM.

C.6.1.5. The Contractor shall process claims submitted using either the beneficiary’s social security number (SSN) or an alternative government identification number up to 12 digits in length, such as the

DoD Benefits Number (DBN). The primary identifier used by the Contractor shall be the DEERS ID, as described in the TSM and the Contractor’s system shall link the identifier transmitted by the pharmacy with the DEERS ID.

C.6.1.6. The Contractor shall not authorize payment for a prescription prior to verifying eligibility, except at the direction of the Government. In some cases, the Government may authorize the Contractor to process a set of claims regardless of DEERS eligibility or date of service.

C.6.1.7. The Contractor shall use the beneficiary’s catastrophic cap and deductible status to apply the correct copayment and deductible. The Contractor will then update the CCDD file in accordance with the

TSM. Catastrophic caps for beneficiaries covered under the Continued Heath Care Benefits Program

(CHCBP) shall be maintained in accordance with TOM Chapter 23, Section 3. The Contractor shall provide reporting on the maintenance of CHCBP catastrophic caps (CDRL Q170).

C.6.1.8. During contract phase-in, the Contractor shall provide estimates to DMDC on projected DEERS query volume over the period of performance. Throughout the period of performance, the Contractor shall investigate and revise these estimates as necessary when they differ significantly from actual volumes reported by DEERs. The Contractor shall minimize queries to DEERS for transactions not authorizing payment and as a result of timed-out transactions. The Contractor shall also participate in regular integration testing meetings as directed by the Government throughout the duration of the contract. Daily meetings will occur during integration and transition to biweekly for maintenance.

H94002-13-R-0001 33

C.6.1.9. The Contractor‘s OHI file shall be the system of record. The Contractor’s information must be transmitted to DEERS in accordance with TSM Chapter 3, Section 1.4. In the event that OHI records in

DEERS are inconsistent with the Contractor’s system, the Contractor shall, as part of the claims adjudication process, determine which source is the most reliable. Post-adjudication, the Contractor shall perform reviews to ensure the claim processed correctly and update either system as necessary to maintain consistency. The Contractor shall review its proposed process with the Government during contract phase-in and systems integration.

C.6.1.10. The Contractor shall conduct Prospective Drug Utilization Review (ProDUR) on dispensing transactions submitted by the three points of service: MTF, TMOP, and Retail network pharmacies. As part of the adjudication process, the ProDUR shall evaluate the new prescription against the patient’s current drug regimen and return appropriate clinical warnings or administrative alerts. The Contractor shall also perform other real-time edits (e.g., Prescription Restriction Program restrictions). The

Contractor shall support ProDUR business rules specific to MTFs as outlined in C.6.7.

C.6.1.11. The Contractor shall monitor State of Emergency declarations issued by Federal and State

Governments and make timely recommendations to the Government for implementation of "Emergency

Refill Too Soon Procedures" for areas placed under a state of emergency. The recommendation will include the designated ending date for the state of emergency. Upon approval by the Government, the

Contractor shall have the capability to bypass the refill too soon edit and allow the refill to be processed for areas covered by the state of emergency.

C.6.1.12. Claims for infused and injectable pharmaceutical agents shall be processed in accordance with the TPM, Chapter 8, Section 9.1 and Section 20.1.

C.6.1.13. Copayments shall be charged to beneficiaries in accordance with the TRM, Chapter 2, Addendum B. The Contractor shall not collect any additional fees, rebates, discounts, or premiums specific to processing TRICARE prescriptions other than recoveries (payable to the U.S. Treasury) resulting from audits of network pharmacies. The Contractor shall not negotiate or collect any pharmaceutical rebates, data-use rebates, or vendor charge-backs of any type from pharmaceutical manufacturers, wholesalers, and/or network pharmacies on behalf of the Government or for itself in regard to the services performed under this contract.

C.6.1.14. The Contractor shall maintain a current benefit design document, including formulary restrictions by category. The Contractor's presentation of the benefit design within this document shall remain consistent with the elements of the document initially provided by the Government and shall be in a format agreed to by the Government. The current benefit design document shall be readily accessible for the Government’s review. The Contractor shall maintain a current version of the Payer Sheet (CDRL

A080) distributed to retail network pharmacies, which shall also be made available to the Government.

The combination of the benefit design document, payer sheet, and the interface control document described in C.12 shall provide comprehensive documentation of the Contractor’s adjudication system.

C.6.1.15. The Contractor shall dispense prescriptions in accordance with the TRICARE pharmacy program’s mandatory generic substitution policy, per 32 CFR 199.21. The Contractor shall not accept

Dispense as Written (DAW) 1 codes but may accept other DAW codes when mandated by state law.

C.6.1.16. All claims shall be processed according to benefit design and formulary restrictions in effect on the date of service. For compounded medications, the Contractor shall support benefit design edits applied to each individual ingredient in the compound segment of the National Council for Prescription

Drug Programs (NCPDP) D.0 transaction standard.

H94002-13-R-0001 34

C.6.1.17. The Contractor shall provide the Government with licenses to Medispan and First Data Bank for purposes of calculating the Retail Network Cost Control Incentive.

C.6.1.18. The Contractor shall submit a TED record for all paid claims and clinical reviews conducted under this contract (See C.15.2).

C.6.2. Other Health Insurance

C.6.2.1. The Contractor shall implement processes to maximize the identification of OHI, including but not limited to utilizing commercial services or data sources. When new OHI is identified, the Contractor shall pursue recoupment for past claims and build out the beneficiary’s profile for future claims. In all cases where possible OHI is identified, including but not limited to leads provided by the Managed Care

Support Contractors (MCSC) or pharmaceutical manufacturers, the Contractor shall investigate and develop OHI records in accordance with TOM, Chapter 23, Section 3, TOM Chapter 10, Section 5, and

TRM, Chapter 4. When the Contractor identifies beneficiary OHI through sources other than DEERS

(e.g., claim forms, beneficiary declarations, Contractor’s internal files), it shall forward the OHI information to DEERS in accordance with the TSM. The Contractor shall provide a reporting to the

Government on OHI development (CDRL Q190).

C.6.2.2. A beneficiary with OHI cannot use TMOP, unless the OHI does not cover the prescribed pharmaceutical or the beneficiary has exhausted the benefits under the OHI. To receive TRICARE coverage of pharmaceuticals dispensed through the TMOP, the beneficiary must submit documentation from the OHI to the Contractor showing that the OHI does not cover the prescribed item or an

Explanation of Benefits (EOB) indicating that coverage has been exhausted.

C.6.3. Retail Network Claims

C.6.3.1. The Contractor shall accept and process all claims for pharmaceutical agents and diabetic supplies covered under the TRICARE pharmacy benefit, and purchased from a licensed pharmacy in the

50 United States, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Northern Mariana

Islands, American Samoa and Guam.

C.6.3.2. Retail claims for covered drugs will be limited by requirements under 10 U.S.C. 1074g, 32 CFR

199.21, and other applicable regulations. Network pharmacies may submit claims for covered supply items using the National Drug Code (NDC) numbers assigned to them. When access to specific drugs at retail pharmacies is restricted under the law, the Contractor shall facilitate either a change in the beneficiary’s current prescription to an approved pharmaceutical or supply, or shift the beneficiary’s prescription to TMOP. Covered drugs that are restricted at retail and their respective implementation dates are published at http://pec.ha.osd.mil/pt_minutes.php.

C.6.3.3. Claims received for covered drugs furnished in geographical locations not covered under this contract shall be forwarded to the TRICARE contractor responsible for processing claims for those locations as specified in the TOM, Chapter 8, Section 2.

C.6.3.4. The Contractor shall complete real-time, online Coordination of Benefits (COB) in accordance

NCPDP D.0 standards (or most current version) for those claims filled in retail network pharmacies where

OHI has been identified, to include Medicare Part D claims. The Government will provide the COB and

Medicare Part D billing transaction segments to include the required values. The Contractor is required to track Medicare Part D True Out-Of-Pocket expenses (TROOP) and total drug expenditures for each

TRICARE beneficiary who is also enrolled in Medicare Part D. The Contractor shall provide this

H94002-13-R-0001 35 information to the Centers for Medicare & Medicaid Services (CMS) designated TROOP facilitator. The

Contractor shall reimburse claims in accordance with the TRM, Chapter 4.

C.6.3.5. If requested by the beneficiary and allowable under federal and state law, the Contractor may authorize the dispensing of up to a 90-day supply prescription as a single transaction at a retail pharmacy.

In these cases, the pharmacy shall collect a copayment for each 30-day increment. The Contractor must make this option available at all retail network pharmacies.

C.6.3.6. Claims for prescriptions filled but not dispensed (non-compliant) shall be reversed within ten

(10) calendar days of the date the original claim was submitted. Reversals processed more than ten (10) calendar days after the date the original claim was submitted will require an adjusted or cancelled TED record.

C.6.3.7. The Contractor shall process batch claims in the most current NCPDP batch format. The

Contractor may receive batch claims from a variety of sources (e.g., State Medicaid agencies, clearinghouses, DVA) and the Contractor shall process these claims regardless of the electronic media

(e.g., CD ROM, tapes) through which they are submitted. All batch claims shall be processed within 14 days of receipt. The Contractor must review historical claims for duplicate claims. Duplicate claims will not be processed.

C.6.4. Paper Claims

The Contractor shall process paper claims also known as direct member reimbursement (DMR) claims in accordance with TOM, Chapter 23, Section 3, Paragraph 1.2 and Chapter 8, Section 1, Paragraph 3.1.

This includes the processing of assignment of benefit claims. The Contractor shall accept claims submitted using any of the specified forms. Upon request, the Contractor shall mail the current version of the DD2642 claim form to beneficiaries. Paper claims for non-network pharmacy services shall be reimbursed in accordance with the TRM, Chapter 1, Section 15, minus applicable copayments and deductibles. The Contractor shall process these claims using the most current NCPDP format. The

Contractor shall monitor paper claims processing and work with retail network pharmacies to reduce the volume of network paper claims and encourage electronic submission.

C.6.4.1. Claims for beneficiaries who are required by their OHI to use their designated mail order pharmacy are to be processed using network cost shares. Non-network copayments and deductibles are not applicable to these claims.

C.6.4.2. Measured on a monthly basis, paper claims shall meet the following minimum standards:

95% of paper claims shall be processed to completion within 14 calendar days of receipt.

100% of paper claims shall be processed to completion within 28 calendar days of receipt.

The Contractor shall provide reporting on paper claims volumes, processing times, denials and appeals

(CDRL Q010 and Q020).

C.6.4.3. For denied paper claims, notification to the beneficiary must be in writing. The notification must explain why the claims were denied and detail the beneficiary's appeal rights.

C.6.4.4. Under the TRICARE benefit, the Contractor shall not process paper claims for prescriptions filled at MTF pharmacies. If necessary, the Contractor may forward the claims to its commercial services section for review as a claim payable by a commercial insurance plan.

H94002-13-R-0001 36

C.6.5. Retail Pharmacy Network

C.6.5.1. The Contractor shall establish and maintain a retail pharmacy network throughout the 50 United

States, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and Guam. The Contractor shall provide network retail pharmacy services in American Samoa and the Northern Mariana Islands when they become eligible. The Contractor’s retail pharmacy network shall meet the following four minimum access standards (see definitions (Access Standards)TOM, Appendix B):

Urban: a pharmacy within two (2) miles estimated driving distance of ____% of the beneficiaries.

Suburban: a pharmacy within five (5) miles estimated driving distance of __% of the beneficiaries.

Rural: a pharmacy within fifteen (15) miles estimated driving distance of ___% of the beneficiaries.

No less than ________ retail network pharmacies.

The Contractor shall provide reports identifying retail network pharmacies and the total network size

(CDRL M010) and network access relative to the above metrics (CDRL M020).

C.6.5.2. All network pharmacies shall be fully licensed in accordance with applicable Federal and State laws and have a current NCPDP number. Pharmacies providing pharmaceuticals solely through Internet or mail order pharmacies shall not be included in the retail network. Retail pharmacies who offer to mail prescriptions to beneficiaries as part of their business may be included in the network subject to the retail pharmacy specifications listed herein.

C.6.5.3. The Contractor shall support online adjudication for claims received from DVA, Public Health

Service (PHS), and Indian Health Service (IHS) pharmacies identified by the Government. The reimbursement amount for pharmaceuticals dispensed through these pharmacies will be directed by the

Government, in accordance with agency agreements. These pharmacies will be paid the submitted costs plus a dispensing fee negotiated by the Government. Dispensing fees may be updated annually. These pharmacies shall not be included in performance measurement of network access standards nor in the calculation of the Retail Network Cost Control incentive under H.1.

C.6.5.4. At a minimum, the retail pharmacies shall provide TRICARE beneficiaries the same quality of services provided to beneficiaries of other commercial clients, to the extent allowed by Federal regulation and this contract. The Contractor shall ensure that all pharmacies document the receipt of the medication by the beneficiary or the individual authorized by the beneficiary, in accordance with all applicable State and Federal Laws. The Contractor shall ensure that network pharmacies have procedures to reasonably assess the validity of prescriptions ordered by telephone.

C.6.6. Retail Network Changes

C.6.6.1. The Contractor shall have a plan for communicating to beneficiaries when a pharmacy is removed from the retail network. As part of the plan, the Contractor shall do the following:

Provide the Government with the names of all pharmacies selected for removal from the network no later than 60 days prior to the effective date of the changes.

Identify and provide advance notification to beneficiaries who have filled prescriptions at the designated pharmacies during the previous six (6) months. The Contractor shall ensure that the beneficiary receives the letter no later than 30 days prior to the effective date of the change.

Provide the Government with samples of all beneficiary correspondence related to the change in the network for comment. The Government shall have no less than 14 days to review.

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C.6.6.2. Additionally, to ensure continuity of therapy and minimize the impact of network changes on beneficiaries utilizing retail network pharmacies designated as specialty pharmacies by the Contractor, the

Contractor shall perform the following steps:

No later than 60 days prior to the effective date of the change, identify and provide to the

Government the number of affected beneficiaries by the following categories: Specialty

Medications, Limited Distribution Medications, Hemophilia Medications and Other Non-

Specialty.

Perform outreach by letter, phone and/or other electronic means to beneficiaries utilizing specialty, limited distribution and hemophilia medications, which includes messaging specific to each population.

Develop an approach to evaluating the effectiveness of the plan in minimizing disruption of therapy among the affected specialty, limited distribution, and hemophilia populations.

Submit a weekly report to the Government on the actions taken as part of its plan and the effectiveness of these actions (CDRL R010). Reporting shall commence when the Contractor begins its communication efforts and continue for 180 days after the effective date of the change.

Reporting may be discontinued sooner if notified by the Government.

Submit a final weekly report of all beneficiaries from the specialty, limited distribution, or hemophilia populations where there is not a documented continuation of therapy. The report shall describe all efforts made to contact that patient, including dates attempted and contact methods employed. (CDRL R010)

Make changes to the plan as necessary to ensure successful communication with all beneficiaries and minimize disruption of therapy to specialty, limited distribution, and hemophilia populations.

C.6.7. MTF Claims Adjudication

C.6.7.1. The Contractor shall connect to the DoD MHS electronic medical record, as described in Section

C.12.3. The MHS verifies beneficiary eligibility through an interactive check with the DEERS, then forwards the prescription data to the Contractor for ProDUR before filling the prescription. The MTF assumes responsibility for eligibility; therefore, the Contractor will process the claim regardless of eligibility status.

C.6.7.2. The Contractor shall receive dispensing transactions and profile inquiry transactions from all

MTFs and MTF pharmacies. The Contractor shall perform ProDUR on the inbound dispensing transactions and return the requested data on profile inquiries. All traffic shall be logged and dispensing transactions shall be transmitted to the PDTS data warehouse.

C.6.7.3. The Contractor shall support messaging to the MTF and handling of rejected claims to the MTF that varies from that used by the commercial network. The Contractor shall not reject MTF claims but will instead return ProDUR warning messaging. For purposes of the Data Integrity Reviews described in

C.11.3, claims resulting in certain types of ProDUR warnings will be regarded by the Contractor as rejects. Adjudication of MTF claims shall be conducted in accordance with guidelines provided by the

Government after award.

C.6.8. Benefit Analysis and Trending

The Contractor shall provide analysis, reporting, and benefit design recommendations to allow the

Government to provide a comprehensive and cost-effective pharmacy benefit. This will include a report of plan cost by demographic (CDRL M230) and benchmarked to commercial plans (CDRL Q200).

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C.7. Mail Order Pharmacy

C.7.1.1. The Contractor shall accept prescription orders at TMOP by written (original or facsimile), electronic (supporting digital signature including e-prescribing), or telephonic submission. The Contractor shall have procedures in place to reasonably assess the validity of prescription orders submitted by telephone or fax. For all medications dispensed through TMOP, the Contractor’s tracking and dispensing procedures shall comply with Federal and State law and all applicable state board of pharmacy requirements. The Contractor shall not collect sales tax on prescriptions dispensed by TMOP. For beneficiaries receiving prescription medications through the TMOP, the Contractor shall provide 24 hours a day, 7 days a week access to a pharmacist by phone.

C.7.1.2. TMOP prescription processing and written notification of denied orders shall meet the following minimum standards:

Mail order prescriptions shall be shipped, returned, or denied within ten (10) days of receipt, date stamped in accordance with TOM Chapter 8, Section 1.

Prescriptions dispensed from the TMOP shall be accurate 100% of the time, measured monthly.

In the event the Contractor fails to mail any prescription that did not require clarification or intervention within ten (10) days, the Contractor shall automatically provide next day delivery service at no additional charge to the beneficiary.

C.7.1.3. The Contractor shall provide reporting of mail order volumes, processing times, and accuracy

(CDRL Q030). The Contractor shall provide a data file identifying all beneficiaries using the mail order pharmacy over the reporting period (CDRL Q080).

C.7.1.4. For each TMOP prescription received requiring clarification or intervention, the Contractor shall contact the prescriber as appropriate. If the Contractor is unable to obtain a response from a prescriber within two (2) business days, they shall contact the beneficiary telephonically or by electronic means, based on the beneficiary’s indicated preferences. The Contractor shall provide order status and request beneficiary direction to either hold the prescription for fill, to cancel, or to transfer the prescription to a retail network pharmacy designated by the beneficiary. The Contractor shall document all calls, and the beneficiary’s direction. The Contractor shall not return a prescription without first attempting to contact the beneficiary. For all returned prescriptions, the Contractor must provide written notification to the beneficiary explaining why the prescription was returned.

C.7.1.5. If the beneficiary opts to transfer the prescription to a retail network pharmacy, it shall be processed in accordance with C.6.3. The beneficiary shall have no less than 72 hours to provide a response before the prescription is returned.

C.7.1.6. If the Contractor is unable to fill a prescription because the medication is on national backorder or which has been recalled, the Contractor shall notify the beneficiary at the time of the order. When the medication is back in stock, the Contractor shall contact the beneficiary to request permission to fill the order.

C.7.1.7. TMOP prescriptions dispensed shall adhere to the Government’s mandatory generic policy. The

Contractor will use best commercial practices to maximize generic substitution, including attempts to convert DAW prescriptions. Upon receipt of a DAW prescription for a brand name product for which a generic equivalent is available, the Contractor shall contact the prescriber to change the prescription to a generic equivalent. If the prescriber refuses to switch, then the prescription shall be processed according to government-approved prior authorization criteria, as described in C.9.1. If the prior authorization is denied, the prescription shall be returned to the beneficiary. If the Contractor cannot contact the prescriber, the Contractor shall call the beneficiary, notify them that their prescription will be returned, H94002-13-R-0001 39 and the reason why. For all denied mail order prescriptions, the Contractor must also provide notification to the beneficiary in writing explaining why the order was denied and detailing the beneficiary's appeal rights. At the direction of the Contracting Officer Representative (COR), the Contractor may dispense brand in lieu of generic in instances where the brand is the lowest cost available on the Managed Care

Pricing File (MCPF), provided by the Defense Logistics Agency Troop Support (DLA-TS), for replenishment.

C.7.1.8. For beneficiaries not in deployed theatres of operation the Contractor shall provide notification by telephone or other electronic means, based on beneficiary preference, of prescriptions received and placed in a pended status, and the anticipated processing date for each. For beneficiaries in deployed theaters of operation, the Contractor shall dispense medications as indicated in Section C.7.10.

C.7.1.9. The Contractor shall pend prescriptions in lieu of rejecting early submissions and notify the beneficiary that the prescription has been pended with the next possible fill date.

C.7.1.10. The Contractor may offer automatic refills but shall exclude specific drugs from this service as determined by the P&T process.

C.7.1.11. Dispensed ingredients shall be priced on the TED record at the burdened unit price from the

MCPF provided by the DLA-TS. See Section C.7.11 for more information.

C.7.1.12. The Contractor shall accommodate all special requirements in regards to handling, processing or shipping medications as recommended by the Food and Drug Administration (FDA) or manufacturer for products dispensed through TMOP.

C.7.1.13. Mandatory Mail Pilot

The Contractor shall support the mandatory mail pilot at the TMOP point of service as required in NDAA

2013, Section 716. This pilot will end on December 31, 2017 unless extended by Congress. The pilot shall apply to TRICARE For Life (TFL) beneficiaries identified in DEERS when receiving medications identified on the Government’s mandatory mail drug list. The drug list includes select maintenance medications. The Government will provide an updated version of the list upon award and quarterly thereafter.

C.7.1.13.1. Under this pilot, the Contractor shall block prescriptions at retail pharmacies for specified maintenance medications, based on the following criteria:

Applies only to Medicare-Eligible TFL beneficiaries. DEERS will be the source of record to identify current TFL beneficiaries and to identify new TFL beneficiaries as they meet the age requirement. This block will not be applied to those TFL beneficiaries who have identified other health insurance (OHI) coverage.

Will be applied based upon a list of specified maintenance medications approved by the

Government. Once the approved list of covered drugs is established, it will be modified by the

Government, but not more than quarterly.

Will be applied separately for individual beneficiaries and for each of their covered medications.

o Once a block is established, the Contractor will allow for two (2) refills at a retail pharmacy as a courtesy to give beneficiaries time to shift of their prescription to MOP / MTF. Refill quantity will be limited to no more than a 30-day supply each.

o Subsequent to these two (2) refills, a retail pharmacy may request and the Contractor will grant override(s) for an emergency refill of a prescription for a covered medication. All mandatory mail medications filled at a retail pharmacy will be subject to a 100% cost share.

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C.7.1.13.2. When the Contractor processes a retail pharmacy claim for a beneficiary subject to this pilot, the Contractor will communicate program information to the beneficiary. The Contractor will contact the beneficiary by letter within 7 days after each of the two (2) potential courtesy refills, reminding the beneficiary of their options for obtaining future refills (refills at MTF, MOP or pay 100% cost share at retail), contact information for the Contractor’s call center, and circumstances in which the beneficiary may opt-out of the pilot.

C.7.1.13.3. The Contractor shall provide assistance to the beneficiary in transferring the prescription to an MTF or TMOP, based on the beneficiary’s direction, as described under C.7.7.

C.7.1.13.4. The Contractor will establish/manage a process allowing beneficiaries to opt-out (i.e. override the block) in the following circumstances:

After one (1) year, the beneficiary may choose to opt-out of mandatory mail for all covered drugs.

The one (1) year period will be measured from the date on which the beneficiary’s first prescription for a covered prescription (previously filled at retail) was filled at the MOP.

A TFL beneficiary who resides in a nursing home may opt-out of mandatory mail for all covered drugs at their discretion. Communication with the beneficiary, a relative or a caregiver is sufficient to establish residency in a nursing home.

Approval of a Prior Authorization (PA) request for a specific drug based on personal need, hardship, emergency, or other special circumstance. The criteria for this PA will be developed by the Contractor in consultation with the Government.

C.7.1.13.5. If the Contractor is unable to fill a medication subject to the mandatory mail policy at TMOP, the Contractor shall attempt to transfer the prescription to the retail pharmacy of the beneficiary's choice.

The Contractor shall enter a point-of-service override at the time of the transfer to ensure that the prescription will not be rejected at retail.

C.7.1.13.6. The Contractor shall deny payment on any paper claims submitted by TFL beneficiaries for a medication that was subject to a 100% cost share under this pilot.

C.7.2. Mail Order Pharmacy Accounts

C.7.2.1. The Contractor shall support TMOP registration by a variety of means, including but not limited to submissions in writing, via telephone, or via the Contractor’s website. When the Contractor receives a prescription transfer from an MTF (as described in C.7.8) for a beneficiary without an existing MOP account, the Contractor shall create an account using the information…