Amendment_0003.pdf

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

1 2

2. AMENDMENT/MODIFICATION NO.

000003

3. EFFECTIVE DATE

08/15/2013

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 x is extended, 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 0003 is to extend the proposal due date in Block 9 of the SF33; revise Section C, DESCRIPTION/SPECIFICATION /STATEMENT OF WORK; Section L, INSTRUCTIONS, CONDITIONS AND NOTICES TO OFFERORS; Exhibit L-1, RETAIL NETWORK REIMBURSMENT TABLE; Exhibit L-10, HISTORICAL DATA AND OTHER INFORMATION AVAILABLE TO OFFERORS; and Exhibit L-11, INSTRUCTIONS TO ORDER – CONFIDENTIAL AND PROTECTED DATA.

(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 0003, SOLICITATION HT9402-13-R-0001

B. Due to DoD Government furloughs and other unexpected delays during the solicitation phase, the proposal due date on Standard Form 33 is revised as follows:

1) Extend the proposal due date specified in block 9 FROM: 08/30/2013 TO: 09/11/2013

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

1) Change paragraph C.5.2.

FROM: “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 81 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 “

TO: “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 102 o TRICARE Policy Manual (TPM) 6010.57-M dated February 1, 2008, at change 94 o TRICARE Reimbursement Manual (TRM) 6010.58-M dated February 1, 2008, at change 84 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 50 “

2) Add the following sentence to the end of paragraph C.6.1.5.:

“The Contractor shall dynamically link all variations of patient IDs to ensure a single patient-centric perspective.”

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

1) Section L, Paragraph L.10.15.1. Change the fourth sentence FROM: “Offerors shall prepare the table in exhibit L-1 in accordance with the instructions provided as “Instructions and Notes for Completing Retail Network Reimbursement Table L-1” immediately following the table.”

TO: “Offerors shall prepare the table in exhibit L-1 in accordance with the instructions provided at exhibit L-12, Instructions and Notes for Completing Retail Network Reimbursement Table L-1.”

2) Add the following exhibits to paragraph L.12.:

L-12 Instructions for Completing Retail Network Reimbursement, Table L-1

L-13 Background Information for Retail Network Reimbursement, Table L-1

E. Exhibit L-1, RETAIL NETWORK REIMBURSEMENT TABLE is removed and replaced with the attached revised L-1, RETAIL NETWORK REIMBURSEMENT TABLE.

F. Exhibit L-10, HISTORICAL DATA AND OTHER INFORMATION AVAILABLE TO OFFERORS is removed and replaced with the attached revised Exhibit L-10, HISTORICAL DATA AND OTHER INFORMATION

AVAILABLE TO OFFERORS

G. Exhibit L-11, INSTRUCTIONS TO ORDER “CONFIDENTIAL AND PROTECTED INFORMATION” is removed and replaced with the attached revised L-11, INSTRUCTIONS TO ORDER “CONFIDENTIAL AND

PROTECTED INFORMATION”

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

HT9402-13-R-0001

SOLICITATION, OFFER AND AWARD

4. TYPE OF SOLICITATION2. CONTRACT NUMBER 3. SOLICITATION NUMBER

7. ISSUED BY CODE 8. ADDRESS OFFER TO (If other than Item 7)

ORDER UNDER DPAS (15 CFR 700)

6. REQUISITION/PURCHASE NUMBER

NOTE: In sealed bid solicitations "offer" and "offeror" mean "bid" and "bidder".

NEGOTIATED (RFP)

SEALED BID (IFB)

5. DATE ISSUED

1. THIS CONTRACT IS A RATED RATING PAGE OF PAGES

C-9 1 160

C. E-MAIL ADDRESS

EXT.NUMBERAREA CODE

B. TELEPHONE (NO COLLECT CALLS)A. NAME

10. FOR

INFORMATION

CALL:

CAUTION: LATE Submissions, Modifications, and Withdrawals: See Section L, Provision No. 52.214-7 or 52.215-1. All offers are subject to all terms and conditions contained in this solicitation.

(Date)(Hour) local timeuntildepository located in copies for furnishing the supplies or services in the Schedule will be received at the place specified in Item 8, or if hand carried, in the

SOLICITATION

9. Sealed offers in original and

PART IV - REPRESENTATIONS AND INSTRUCTIONS

OTHER STATEMENTS OF OFFERORS

EVALUATION FACTORS FOR AWARD

INSTRS., CONDS., AND NOTICES TO OFFERORS

REPRESENTATIONS, CERTIFICATIONS AND

LIST OF ATTACHMENTS

CONTRACT CLAUSES

PART III - LIST OF DOCUMENTS, EXHIBITS AND OTHER ATTACH.

I

J

K

L

M SPECIAL CONTRACT REQUIREMENTS

CONTRACT ADMINISTRATION DATA

DELIVERIES OR PERFORMANCE

INSPECTION AND ACCEPTANCE

PACKAGING AND MARKING

DESCRIPTION/SPECS./WORK STATEMENT

SUPPLIES OR SERVICES AND PRICES/COSTS

SOLICITATION/CONTRACT FORM

PART II - CONTRACT CLAUSESPART I - THE SCHEDULE

H

G

F

E

D

C

B

A

SEC. DESCRIPTION PAGE(S) (X) DESCRIPTION SEC. (X)

11. TABLE OF CONTENTS

18. OFFER DATE17. SIGNATURE

SUCH ADDRESS IN SCHEDULE.

IS DIFFERENT FROM ABOVE - ENTER

15C. CHECK IF REMITTANCE ADDRESS

EXT.NUMBERAREA CODE

15B. TELEPHONE NUMBER

(Type or print)AND

ADDRESS

OF

OFFEROR

CODE FACILITY

16. NAME AND TITLE OF PERSON AUTHORIZED TO SIGN OFFER15A. NAME

DATEAMENDMENT NO.DATEAMENDMENT NO.

and related documents numbered and dated):

amendments to the SOLICITATION for offerors

(The offeror acknowledges receipt of

14. ACKNOWLEDGEMENT OF AMENDMENTS

CALENDAR DAYS (%)30 CALENDAR DAYS (%)20 CALENDAR DAYS (%)10 CALENDAR DAYS (%)

(See Section I, Clause No. 52.232.8)

13. DISCOUNT FOR PROMPT PAYMENT

designated point(s), within the time specified in the schedule.

by the offeror) from the date for receipt of offers specified above, to furnish any or all items upon which prices are offered at the price set opposite each item, delivered at the

12. In compliance with the above, the undersigned agrees, if this offer is accepted within ______________ calendar days (60 calendar days unless a different period is inserted

NOTE: Item 12 does not apply if the solicitation includes the provisions at 52.214-16, Minimum Bid Acceptance Period.

OFFER (Must be fully completed by offeror)

IMPORTANT - Award will be made on this Form, or on Standard Form 26, or by other authorized official written notice.

28. AWARD DATE

(Signature of Contracting Officer)

27. UNITED STATES OF AMERICA

25. PAYMENT WILL BE MADE BY

26. NAME OF CONTRACTING OFFICER (Type or print)

CODE 24. ADMINISTERED BY (If other than Item 7)

ITEM

(4 copies unless otherwise specified)

23. SUBMIT INVOICES TO ADDRESS SHOWN IN

41 U.S.C. 253 (c) ( 10 U.S.C. 2304 (c) (

22. AUTHORITY FOR USING OTHER THAN FULL AND OPEN COMPETITION:

21. ACCOUNTING AND APPROPRIATION20. AMOUNT19. ACCEPTED AS TO ITEMS NUMBERED

AWARD (To be completed by government)

CODE

06/27/2013 X

HT9402

DEPARTMENT OF DEFENSE

TRICARE MANAGEMENT ACTIVITY COD

16401 E CENTRETECH PARKWAY

AURORA CO 80011-9066

1400 MS 09/11/2013

MATTHEW ANDERSON 303

matthew.anderson@tma.osd.mil

676-3754

X

X

X

X

X

X

X

X

X

X

X

X

PAGE(S)

Bruce Mitterer

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (Rev. 9-97)

Prescribed by GSA - FAR (48 CFR) 53.214(c)

303.676.3812 bruce.mitterer@tma.osd.mil

MAnderson Typewritten Text See Section L

MAnderson Typewritten Text See Section L

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

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(A) (B) (C) (D) (E) (F)

0001 Contract Phase-In, TRICARE 1 LT Type: Firm Fixed Price Product/Service Code: Q201

0002 Government Directed Mailings 250000 EA Type: Requirements Est Qty: 250,000 Product/Service Code: Q201

0003 Contract Data Requirements List (CDRLs) 1 LT Exhibit A Type: Firm Fixed Price Product/Service Code: Q201

1001 Retail Network Claims, Electronic, 40700000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 40,700,000 (Option Line Item) Product/Service Code: Q201

1002 Retail Network Claims, Electronic, 32000000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 32,000,000 (Option Line Item) Product/Service Code: Q201

1003 Retail Claims, Paper, 560000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 560,000 (Option Line Item) Product/Service Code: Q201

1004 Retail Claims, Paper, 440000 EA Medicare Dual-Eligible Continued ...

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(A) (B) (C) (D) (E) (F)

Type: Requirements Est Qty: 440,000 (Option Line Item) Product/Service Code: Q201

1005 MTF Prescriptions, Adjudication Services 58000000 EA Type: Requirements Est Qty: 58,000,000 (Option Line Item) Product/Service Code: Q201

1006 Mail Order Pharmacy, Prescription Fill, 10400000 EA TRICARE Only-Eligible, Type: Requirements Est Qty: 10,400,000 (Option Line Item) Product/Service Code: Q201

1007 Mail Order Pharmacy, Prescription Fill, 13230000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 13,230,000 (Option Line Item) Product/Service Code: Q201

1008 Mail Order Pharmacy, Specialty Clinical Svcs, 23500 EA TRICARE Only-Eligible Type: Requirements Est Qty: 23,500 (Option Line Item) Product/Service Code: Q201

1009 Mail Order Pharmacy, Specialty Clinical Svcs, 18500 EA Medicare Dual-Eligible Type: Requirements Est Qty: 18,500 (Option Line Item) Product/Service Code: Q201

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(A) (B) (C) (D) (E) (F)

1010 Mail Order Unreplenished Agents 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

1011 Clinical Reviews, Prior Authorization & Medical 168000 EA Necessity, TRICARE Only-Eligible Type: Requirements Est Qty: 168,000 (Option Line Item) Product/Service Code: Q201

1012 Clinical Reviews, Prior Authorization & Medical 132000 EA Necessity, Medicare Dual-Eligible Type: Requirements Est Qty: 132,000 (Option Line Item) Product/Service Code: Q201

1013 Explanation of Benefits (EOB) 5000000 EA Type: Requirements Est Qty: 5,000,000 (Option Line Item) Product/Service Code: Q201

1014 Government Directed Mailings 1000000 EA Type: Requirements Est Qty: 1,000,000 (Option Line Item) Product/Service Code: Q201

1015 Contract Data Requirements List (CDRLs), 1 LT Exhibit A Type: Firm Fixed Price (Option Line Item)

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(A) (B) (C) (D) (E) (F)

1016 Retail Network Cost Control Incentive 1 LT NSP (Option Line Item) (Not Separately Priced) Product/Service Code: Q201

1017 Incentive for Savings on High Cost Medications 1 LT NSP (Option Line Item) (Not Separately Priced) Product/Service Code: Q201

1018 Transfer New Retail Prescription to Mail Order 392000 EA Pharmacy Incentive, TRICARE Only-Eligible Est Qty: 392,000 (Option Line Item) Product/Service Code: Q201

1019 Transfer New Retail Prescription to Mail Order 308000 EA Pharmacy Incentive, Medicare Dual-Eligible Est. Qty: 308,000 (Option Line Item) Product/Service Code: Q201

1020 Transfer New Retail Prescription to MTF 44800 EA Incentive, TRICARE Only-Eligible Est Qty: 44,800 (Option Line Item) Product/Service Code: Q201

1021 Transfer New Retail Prescription to MTF 35200 EA Incentive, Medicare Dual-Eligible Est Qty: 35,200 (Option Line Item) Product/Service Code: Q201

1022 Contract Phase-Out to Non-Incumbent 1 LT Type: Firm Fixed Price (Option Line Item)

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(A) (B) (C) (D) (E) (F)

Product/Service Code: Q201

1023 Contract Phase-Out To Incumbent 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

2001 Retail Network Claims, Electronic, 41500000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 41,500,000 (Option Line Item) Product/Service Code: Q201

2002 Retail Network Claims, Electronic, 32600000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 32,600,000 (Option Line Item) Product/Service Code: Q201

2003 Retail Claims, Paper, 532000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 532,000 (Option Line Item) Product/Service Code: Q201

2004 Retail Claims, Paper, 418000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 418,000 (Option Line Item) Product/Service Code: Q201

2005 MTF Prescriptions, Adjudication Services 61000000 EA Type: Requirements Est Qty: 61,000,000

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(A) (B) (C) (D) (E) (F)

(Option Line Item) Product/Service Code: Q201

2006 Mail Order Pharmacy, Prescription Fill, 14550000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 14,550,000 (Option Line Item) Product/Service Code: Q201

2007 Mail Order Pharmacy, Prescription Fill, 10900000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 10,900,000 (Option Line Item) Product/Service Code: Q201

2008 Mail Order Pharmacy, Specialty Clinical Svcs, 24700 EA TRICARE Only-Eligible Type: Requirements Est Qty: 24,700 (Option Line Item) Product/Service Code: Q201

2009 Mail Order Pharmacy, Specialty Clinical Svcs, 19400 EA Medicare Dual-Eligible Type: Requirements Est Qty: 19,400 (Option Line Item) Product/Service Code: Q201

2010 Mail Order Unreplenished Agents 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

2011 Clinical Reviews, Prior Authorization & Medical 185000 EA Necessity, TRICARE Only-Eligible

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(A) (B) (C) (D) (E) (F)

Type: Requirements Est Qty: 185,000 (Option Line Item) Product/Service Code: Q201

2012 Clinical Reviews, Prior Authorization & Medical 145000 EA Necessity, Medicare Dual-Eligible Type: Requirements Est Qty: 145,000 (Option Line Item) Product/Service Code: Q201

2013 Explanation of Benefits (EOB) 5000000 EA Type: Requirements Est Qty: 5,000,000 (Option Line Item) Product/Service Code: Q201

2014 Government Directed Mailings 1000000 EA Type: Requirements Est Qty: 1,000,000 (Option Line Item) Product/Service Code: Q201

2015 Contract Data Requirements List (CDRLs), 1 LT Exhibit A Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

2016 Retail Network Cost Control Incentive 1 LT NSP (Option Line Item) (Not Separately Priced) Product/Service Code: Q201

2017 Incentive for Savings on High Cost Medications 1 LT NSP (Option Line Item) (Not Separately Priced)

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(A) (B) (C) (D) (E) (F)

Product/Service Code: Q201

2018 Transfer New Retail Prescription to Mail Order 384000 EA Pharmacy Incentive, TRICARE Only-Eligible Est Qty: 384,000 (Option Line Item) Product/Service Code: Q201

2019 Transfer New Retail Prescription to Mail Order 302000 EA Pharmacy Incentive, Medicare Dual-Eligible Est Qty: 302,000 (Option Line Item) Product/Service Code: Q201

2020 Transfer New Retail Prescription to MTF 47000 EA Incentive, TRICARE Only-Eligible Est Qty: 47,000 (Option Line Item) Product/Service Code: Q201

2021 Transfer New Retail Prescription to MTF 37000 EA Incentive, Medicare Dual-Eligible Est Qty: 37,000 (Option Line Item) Product/Service Code: Q201

2022 Contract Phase-Out To Non-Incumbent 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

2023 Contract Phase-Out To Incumbent 1 LT Type: Firm Fixed Price (Option Line Item)

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(A) (B) (C) (D) (E) (F)

3001 Retail Network Claims, Electronic, 42300000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 42,300,000 (Option Line Item) Product/Service Code: Q201

3002 Retail Network Claims, Electronic, 33300000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 33,300,000 (Option Line Item) Product/Service Code: Q201

3003 Retail Claims, Paper, 505500 EA TRICARE Only-Eligible Type: Requirements Est Qty: 505,500 (Option Line Item) Product/Service Code: Q201

3004 Retail Claims, Paper, 397000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 397,000 (Option Line Item) Product/Service Code: Q201

3005 MTF Prescriptions, Adjudication Services 64000000 EA Type: Requirements Est Qty: 64,000,000 (Option Line Item) Product/Service Code: Q201

3006 Mail Order Pharmacy, Prescription Fill, 15300000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 15,300,000 (Option Line Item)

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(A) (B) (C) (D) (E) (F)

3007 Mail Order Pharmacy, Prescription Fill, 11500000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 11,500,000 (Option Line Item) Product/Service Code: Q201

3008 Mail Order Pharmacy, Specialty Clinical Svcs, 25900 EA TRICARE Only-Eligible Type: Requirements Est Qty: 25,900 (Option Line Item) Product/Service Code: Q201

3009 Mail Order Pharmacy, Specialty Clinical Svcs, 20400 EA Medicare Dual-Eligible Type: Requirements Est Qty: 20,400 (Option Line Item) Product/Service Code: Q201

3010 Mail Order Unreplenished Agents 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

3011 Clinical Reviews, Prior Authorization & Medical 203000 EA Necessity, TRICARE Only-Eligible Type: Requirements Est Qty: 203,000 (Option Line Item) Product/Service Code: Q201

3012 Clinical Reviews, Prior Authorization & Medical 160000 EA Necessity, Medicare Dual-Eligible Type: Requirements

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(A) (B) (C) (D) (E) (F)

Est Qty: 160,000 (Option Line Item) Product/Service Code: Q201

3013 Explanation of Benefits (EOB) 5000000 EA Type: Requirements Est Qty: 5,000,000 (Option Line Item) Product/Service Code: Q201

3014 Government Directed Mailings 1000000 EA Type: Requirements Est Qty: 1,000,000 (Option Line Item) Product/Service Code: Q201

3015 Contract Data Requirements List (CDRLs), 1 LT Exhibit A Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

3016 Retail Network Cost Control Incentive 1 LT NSP (Option Line Item) (Not Separately Priced) Product/Service Code: Q201

3017 Incentive for Savings on High Cost Medications 1 LT NSP (Option Line Item) (Not Separately Priced) Product/Service Code: Q201

3018 Transfer New Retail Prescription to Mail Order 376500 EA Pharmacy Incentive, TRICARE Only-Eligible Est Qty: 376,500 (Option Line Item)

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3019 Transfer New Retail Prescription to Mail Order 295800 EA Pharmacy Incentive, Medicare Dual-Eligible Est Qty: 295,800 (Option Line Item) Product/Service Code: Q201

3020 Transfer New Retail Prescription to MTF 49400 EA Incentive, TRICARE Only-Eligible Est Qty: 49,400 (Option Line Item) Product/Service Code: Q201

3021 Transfer New Retail Prescription to MTF 38800 EA Incentive, Medicare Dual-Eligible Est Qty: 38,800 (Option Line Item) Product/Service Code: Q201

3022 Contract Phase-Out To Non-Incumbent 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

3023 Contract Phase-Out To Incumbent 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

4001 Retail Network Claims, Electronic, 43175000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 43,175,000 (Option Line Item) Product/Service Code: Q201

4002 Retail Network Claims, Electronic, 36585000 EA

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(A) (B) (C) (D) (E) (F)

Medicare Dual-Eligible Type: Requirements Est Qty: 36,585,000 (Option Line Item) Product/Service Code: Q201

4003 Retail Claims, Paper, 480000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 480,000 (Option Line Item) Product/Service Code: Q201

4004 Retail Claims, Paper, 377400 EA Medicare Dual-Eligible Type: Requirements Est Qty: 377,400 (Option Line Item) Product/Service Code: Q201

4005 MTF Prescriptions, Adjudication Services 67000000 EA Type: Requirements Est Qty: 67,000,000 (Option Line Item) Product/Service Code: Q201

4006 Mail Order Pharmacy, Prescription Fill, 16040000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 16,040,000 (Option Line Item) Product/Service Code: Q201

4007 Mail Order Pharmacy, Prescription Fill, 10300000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 10,300,000 (Option Line Item)

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(A) (B) (C) (D) (E) (F)

4008 Mail Order Pharmacy, Specialty Clinical Svcs, 27200 EA TRICARE Only-Eligible, Type: Requirements Est Qty: 27,200 (Option Line Item) Product/Service Code: Q201

4009 Mail Order Pharmacy, Specialty Clinical Svcs, 21400 EA Medicare Dual-Eligible Type: Requirements Est Qty: 21400 (Option Line Item) Product/Service Code: Q201

4010 Mail Order Unreplenished Agents, 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

4011 Clinical Reviews, Prior Authorization & Medical 223600 EA Necessity, TRICARE Only-Eligible Type: Requirements Est Qty: 223,600 (Option Line Item) Product/Service Code: Q201

4012 Clinical Reviews, Prior Authorization & Medical 175700 EA Necessity, Medicare Dual-Eligible Type: Requirements Est Qty: 175,700 (Option Line Item) Product/Service Code: Q201

4013 Explanation of Benefits (EOB) 5000000 EA Type: Requirements Est Qty: 5,000,000

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(A) (B) (C) (D) (E) (F)

Product/Service Code: Q201

4014 Government Directed Mailings 1000000 EA Type: Requirements Est Qty: 1,000,000 (Option Line Item) Product/Service Code: Q201

4015 Contract Data Requirements List (CDRLs), 1 LT Exhibit A Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

4016 Retail Network Cost Control Incentive 1 LT NSP (Option Line Item) (Not Separately Priced) Product/Service Code: Q201

4017 Incentive for Savings on High Cost Medications 1 LT NSP (Option Line Item) (Not Separately Priced) Product/Service Code: Q201

4018 Transfer New Retail Prescription to Mail Order 339000 EA Pharmacy Incentive, TRICARE Only-Eligible Est Qty: 339,000 (Option Line Item) Product/Service Code: Q201

4019 Transfer New Retail Prescription to Mail Order 266000 EA Pharmacy Incentive, Medicare Dual-Eligible Est Qty: 266,000 (Option Line Item)

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4020 Transfer New Retail Prescription to MTF 51900 EA Incentive, TRICARE Only-Eligible Est Qty: 51,900 (Option Line Item) Product/Service Code: Q201

4021 Transfer New Retail Prescription to MTF 40750 EA Incentive, Medicare Dual-Eligible Est Qty: 40,750 (Option Line Item) Product/Service Code: Q201

4022 Contract Phase-Out To Non-Incumbent 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

4023 Contract Phase-Out To Incumbent 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

5001 Retail Network Claims, Electronic, 44050000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 44,050,000 (Option Line Item) Product/Service Code: Q201

5002 Retail Network Claims, Electronic, 37300000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 37,300,000 (Option Line Item) Product/Service Code: Q201

5003 Retail Claims, Paper, 456000 EA TRICARE Only-Eligible

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Type: Requirements Est Qty: 456,000 (Option Line Item) Product/Service Code: Q201

5004 Retail Claims, Paper, 358400 EA Medicare Dual-Eligible Type: Requirements Est Qty: 358,400 (Option Line Item) Product/Service Code: Q201

5005 MTF Prescriptions, Adjudication Services 70400000 EA Type: Requirements Est Qty: 70,400,000 (Option Line Item) Product/Service Code: Q201

5006 Mail Order Pharmacy, Prescription Fill, 16840000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 16,840,000 (Option Line Item) Product/Service Code: Q201

5007 Mail Order Pharmacy, Prescription Fill, 10830000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 10,830,000 (Option Line Item) Product/Service Code: Q201

5008 Mail Order Pharmacy, Specialty Clinical Svcs, 28600 EA TRICARE Only-Eligible Type: Requirements Est Qty: 28,600 (Option Line Item)

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5009 Mail Order Pharmacy, Specialty Clinical Svcs, 22500 EA Medicare Dual-Eligible Type: Requirements Est Qty: 22,500 (Option Line Item) Product/Service Code: Q201

5010 Mail Order Unreplenished Agents 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

5011 Clinical Reviews, Prior Authorization & Medical 246000 EA Necessity, TRICARE Only-Eligible Type: Requirements Est Qty: 246,000 (Option Line Item) Product/Service Code: Q201

5012 Clinical Reviews, Prior Authorization & Medical 193000 EA Necessity, Medicare Dual-Eligible Type: Requirements Est Qty: 193,000 (Option Line Item) Product/Service Code: Q201

5013 Explanation of Benefits (EOB) 5000000 EA Type: Requirements Est Qty: 5,000,000 (Option Line Item) Product/Service Code: Q201

5014 Government Directed Mailings 1000000 EA Type: Requirements Est Qty: 1,000,000 (Option Line Item)

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5015 Contract Data Requirements List (CDRLs), 1 LT Exhibit A Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

5016 Retail Network Cost Control Incentive 1 LT NSP (Option Line Item) (Not Separately Priced) Product/Service Code: Q201

5017 Incentive for Savings on High Cost Medications, 1 LT NSP (Option Line Item) (Not Separately Priced) Product/Service Code: Q201

5018 Transfer New Retail Prescription to Mail Order 339000 EA Pharmacy Incentive, TRICARE Only-Eligible, Est Qty: 339,000 (Option Line Item) Product/Service Code: Q201

5019 Transfer New Retail Prescription to Mail Order 266000 EA Pharmacy Incentive, Medicare Dual-Eligible Est Qty: 266,000 (Option Line Item) Product/Service Code: Q201

5020 Transfer New Retail Prescription to MTF 58300 EA Incentive, TRICARE Only-Eligible Est Qty: 58,300 (Option Line Item) Product/Service Code: Q201

5021 Transfer New Retail Prescription to MTF 42800 EA

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Incentive, Medicare Dual-Eligible Est Qty: 42,800 (Option Line Item) Product/Service Code: Q201

5022 Contract Phase-Out To Non-Incumbent 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

5023 Contract Phase-Out To Incumbent 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

6001 Retail Network Claims, Electronic, 44900000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 44,900,000 (Option Line Item) Product/Service Code: Q201

6002 Retail Network Claims, Electronic, 38100000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 38,100,000 (Option Line Item) Product/Service Code: Q201

6003 Retail Claims, Paper, 433300 EA TRICARE Only-Eligible Type: Requirements Est Qty: 433,300 (Option Line Item) Product/Service Code: Q201

6004 Retail Claims, Paper, 340500 EA Medicare Dual-Eligible

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Type: Requirements Est Qty: 340,500 (Option Line Item) Product/Service Code: Q201

6005 MTF Prescriptions, Adjudication Services 73930000 EA Type: Requirements Est Qty: 73,930,000 (Option Line Item) Product/Service Code: Q201

6006 Mail Order Pharmacy, Prescription Fill, 17700000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 17,700,000 (Option Line Item) Product/Service Code: Q201

6007 Mail Order Pharmacy, Prescription Fill, 11400000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 11,400,000 (Option Line Item) Product/Service Code: Q201

6008 Mail Order Pharmacy, Specialty Clinical Svcs, 30000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 30,000 (Option Line Item) Product/Service Code: Q201

6009 Mail Order Pharmacy, Specialty Clinical Svcs, 22500 EA Medicare Dual-Eligible Type: Requirements Est Qty: 22,500 (Option Line Item)

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6010 Mail Order Unreplenished Agents 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

6011 Clinical Reviews, Prior Authorization & Medical 270600 EA Necessity, TRICARE Only-Eligible Type: Requirements Est Qty: 270,600 (Option Line Item) Product/Service Code: Q201

6012 Clinical Reviews, Prior Authorization & Medical 212600 EA Necessity, Medicare Dual-Eligible Type: Requirements Est Qty: 212,600 (Option Line Item) Product/Service Code: Q201

6013 Explanation of Benefits (EOB) 5000000 EA Type: Requirements Est Qty: 5,000,000 (Option Line Item) Product/Service Code: Q201

6014 Government Directed Mailings 1000000 EA Type: Requirements Est Qty: 1,000,000 (Option Line Item) Product/Service Code: Q201

6015 Contract Data Requirements List (CDRLs), 1 LT Exhibit A Type: Firm Fixed Price (Option Line Item)

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6016 Retail Network Cost Control Incentive 1 LT NSP (Option Line Item) (Not Separately Priced) Product/Service Code: Q201

6017 Incentive for Savings on High Cost Medications 1 LT NSP (Option Line Item) (Not Separately Priced) Product/Service Code: Q201

6018 Transfer New Retail Prescription to Mail Order 339000 EA Pharmacy Incentive, TRICARE Only-Eligible Est Qty: 339,000 (Option Line Item) Product/Service Code: Q201

6019 Transfer New Retail Prescription to Mail Order 266000 EA Pharmacy Incentive, Medicare Dual-Eligible Est Qty: 266,000 (Option Line Item) Product/Service Code: Q201

6020 Transfer New Retail Prescription to MTF 57200 EA Incentive, TRICARE Only-Eligible Est Qty: 57,200 (Option Line Item) Product/Service Code: Q201

6021 Transfer New Retail Prescription to MTF 44900 EA Incentive, Medicare Dual-Eligible Est Qty: 44,900 (Option Line Item) Product/Service Code: Q201

6022 Contract Phase-Out To Non-Incumbent, 1 LT Type: Firm Fixed Price

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(Option Line Item) Product/Service Code: Q201

6023 Contract Phase-Out To Incumbent, 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

7001 Retail Network Claims, Electronic, 45820000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 45,820,000 (Option Line Item) Product/Service Code: Q201

7002 Retail Network Claims, Electronic, 38820000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 38,820,000 (Option Line Item) Product/Service Code: Q201

7003 Retail Claims, Paper, 411700 EA TRICARE Only-Eligible Type: Requirements Est Qty: 411,700 (Option Line Item) Product/Service Code: Q201

7004 Retail Claims, Paper, 323400 EA Medicare Dual-Eligible Type: Requirements Est Qty: 323,400 (Option Line Item) Product/Service Code: Q201

7005 MTF Prescriptions, Adjudication Services 77600000 EA Type: Requirements

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Est Qty: 77,600,000 (Option Line Item) Product/Service Code: Q201

7006 Mail Order Pharmacy, Prescription Fill, 18600000 EA TRICARE Only-Eligible Type: Requirements Est Qty: 18,600,000 (Option Line Item) Product/Service Code: Q201

7007 Mail Order Pharmacy, Prescription Fill, 11900000 EA Medicare Dual-Eligible Type: Requirements Est Qty: 11,900,000 (Option Line Item) Product/Service Code: Q201

7008 Mail Order Pharmacy, Specialty Clinical Svcs, 31500 EA TRICARE Only-Eligible Type: Requirements Est Qty: 31,500 (Option Line Item) Product/Service Code: Q201

7009 Mail Order Pharmacy, Specialty Clinical Svcs, 23500 EA Medicare Dual-Eligible Type: Requirements Est Qty: 23,500 (Option Line Item) Product/Service Code: Q201

7010 Mail Order Unreplenished Agents 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

7011 Clinical Reviews, Prior Authorization & Medical 298000 EA

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Necessity, TRICARE Only-Eligible Type: Requirements Est Qty: 298,000 (Option Line Item) Product/Service Code: Q201

7012 Clinical Reviews, Prior Authorization & Medical 234000 EA Necessity, Medicare Dual-Eligible Type: Requirements Est Qty: 234,000 (Option Line Item) Product/Service Code: Q201

7013 Explanation of Benefits (EOB) 5000000 EA Type: Requirements Est Qty: 5,000,000 (Option Line Item) Product/Service Code: Q201

7014 Government Directed Mailings 1000000 EA Type: Requirements Est Qty: 1,000,000 (Option Line Item) Product/Service Code: Q201

7015 Contract Data Requirements List (CDRLs), 1 LT Exhibit A Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

7016 Retail Network Cost Control Incentive 1 LT NSP (Option Line Item) (Not Separately Priced)

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7017 Incentive for Savings on High Cost Medications 1 LT NSP (Option Line Item) (Not Separately Priced) Product/Service Code: Q201

7018 Transfer New Retail Prescription to Mail Order 339000 EA Pharmacy Incentive, TRICARE Only-Eligible Est Qty: 339,000 (Option Line Item)

7019 Transfer New Retail Prescription to Mail Order 266000 EA Pharmacy Incentive, Medicare Dual-Eligible Est Qty: 266,000 (Option Line Item) Product/Service Code: Q201

7020 Transfer New Retail Prescription to MTF 60000 EA Incentive, TRICARE Only-Eligible Est Qty: 60,000 (Option Line Item) Product/Service Code: Q201

7021 Transfer New Retail Prescription to MTF 47200 EA Incentive, Medicare Dual-Eligible Est Qty: 47200 (Option Line Item) Product/Service Code: Q201

7022 Contract Phase-Out To Non-Incumbent 1 LT Type: Firm Fixed Price (Option Line Item) Product/Service Code: Q201

7023 Contract Phase-Out To Incumbent 1 LT Type: Firm Fixed Price

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 102 o TRICARE Policy Manual (TPM) 6010.57-M dated February 1, 2008, at change 94 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 50

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. The Contractor shall dynamically link all variations of patient IDs to ensure a single patient-centric perspective.

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.