Amendment_0004.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

1. CONTRACT ID CODE PAGE OF PAGES

1 8

2. AMENDMENT/MODIFICATION NO.

00004

3. EFFECTIVE DATE

08/30/2013

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 0004 is to extend the proposal due date in Block 9 of the

SF33; revise Section C, DESCRIPTION/SPECIFICATION /STATEMENT OF WORK; Section G, CONTRACT ADMINISTRATION DATA; Section H, SPECIAL CONTRACT REQUIREMENTS; Update and add CDRLs to the list in Section F, DELIVERIES OR PERFORMANCE; and add Exhibit L-14 to the list Section L, INSTRUCTIONS, CONDITIONS AND NOTICIES 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 0004, SOLICITATION HT9402-13-R-0001

B. The proposal due date on Standard Form 33 is revised as follows:

1) Extend the proposal due date specified in block 9 FROM: 09/11/2013 TO: 09/27/2013

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

1) ADD paragraph C.4.10. which reads:

“Before the start of pharmacy services, the Government will provide (via previous contractors) batch files containing all retail, mail and MTF claims along with prior authorization and medical necessity determinations for the past two year period. The Government (via the outgoing contractor) will also provide an OHI data file.”

2) Section C, Paragraph C.5.2. Change the first bullet:

FROM: “TRICARE Operations Manual (TOM) 6010.56-M dated February 1, 2008, at change 102”

TO: “TRICARE Operations Manual (TOM) 6010.56-M dated February 1, 2008, at change 103”

3) Change paragraph C.6.1.10.

FROM: “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.”

TO: 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 that may be specific to DoD and fall outside standard commercial practice, including Prescription Restriction Program restrictions and safety reviews established through the

Uniform Formulary process. The Contractor shall support ProDUR business rules specific to the point of service.”

4) Change paragraph C.6.1.16.

FROM: “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.”

TO: “During the period of performance, the Contractor shall be responsible for processing claims for dates of service prior to the start of pharmacy services under this contract. This includes initial submission of claims; and also any adjustments, corrections, or cancellations necessary for claims previously processed to completion by the outgoing Contractor. If/when the Contractor receives a claim to process that is greater than two years old and the Contractor did not receive relevant information during phase-in; the

Contractor will do the necessary research to process the claim. All claims shall be processed according to benefit design and formulary restrictions in effect on the date of service.”

5) Renumber paragraph numbers C.6.1.17 and C.6.1.18. to C.6.1.18 and C.6.1.19.

6) Add paragraph C.6.1.17 which reads:

“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.”

7) Change paragraph C.6.7.2.

FROM: “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.”

TO: “The Contractor shall receive dispensing transactions and profile inquiry transactions from all MTFs and MTF pharmacies. Profile inquiries are based on the NCPDP 3.2 variable format, while dispensing transactions are based on NCPDP D.0. The D.0 format used by the MTFs does not include the

Coordination of Benefits segment. In addition to a DEA Number or NPI, the Contractor shall accept provider SSN on MTF claims. Formulary edits are not applicable but the Contractor shall perform

ProDUR on the inbound dispensing transactions and return the requested data on profile inquiries. The

Contractor does not create TEDs for these claims. The Contractor will accept and log all data provided on transactions. All transactions shall be transmitted to the PDTS data warehouse.”

8) Change paragraph C.6.7.3.

FROM: “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. “

TO: “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. All MTF claims are considered dispensed unless reversed by the MTF and must be posted to the profile.

• Validity Rejects: When the Contractor is unable to process a claim due to missing or invalid data, the Contractor will follow the processes outlined in C.11.3.3 to correct and resubmit the claim. For patient safety reasons, all clams must be successfully resubmitted, posted to the patient profile and transmitted to the data warehouse, unless the Contractor is notified by the MTF to allow the reject to stand.

• ProDUR Alerts: The Contractor shall not reject MTF claims for ProDURs but will instead return custom ProDUR alert messaging. The MTF will respond to the alert by either cancelling the prescription or entering an override code. The Contractor will receive a reversal if the prescription is cancelled, but if the MTF enters an override code, no additional message will be sent to the

Contractor. MTF claims resulting specific ProDUR Alerts will be included on the Data Integrity

Report described in C.11.3.5.”

9) ADD paragraph C.6.7.4. which reads:

“If an ingredient cost of a penny ($0.01) is submitted by the MTF, the Contractor will recalculate the ingredient cost primarily using the MCPF supplied by DLA-TS, or using AWP as a secondary source. For claims priced from either the MCPF or AWP, the Contractor shall apply a regional discount established by

DLA-TS, based on the NCPDP Pharmacy ID. If the ingredient cost submitted by the MTF is greater than a penny ($0.01), the Contractor shall post the claim and no regional discount is applied.”

10) ADD the acronym “(DPP)” at the end of C.7.10.

11) Section C, Paragraph C.7.10.3. Add the following to the end of the paragraph:

“DPP prescriptions may have additional restrictions, as stipulated at http://pec.ha.osd.mil/PMART/deployment.php.”

12) Change the first sentence under paragraph C.7.10.4.

FROM: “In support of the Deployment Prescription Program (DPP), the Contractor shall establish communication and maintain a current point of contact at all Centers.”

TO: “In support of the DPP, the Contractor shall establish communication and maintain a current point of contact at all Centers.”

13) Correct references in bullet #5 under paragraph C.7.10.5.

FROM: “If prescription is to be pended, continue to (f). If for immediate fill, skip to (g).”

TO: “If prescription is to be pended, continue to (6). If for immediate fill, skip to (7).”

14) Change paragraph C.9.2.1.

FROM: “MTF pharmacies perform their own clinical review and the Government deems that the requirement for prior authorization for a drug has been satisfied if that drug has been dispensed at an MTF pharmacy. Upon receiving a claim for a medication requiring prior authorization from an MTF, the

Contractor shall generate a PA including:

• Identification of Beneficiary

• Identification of Drug at the desired level of granularity

• Effective and Termination Dates of the PA

The resulting auto-generated PA for an MTF dispensing shall be applicable to the dispensing of the medication at other points of service. The auto-generated PA shall be transmitted to the PDTS Contractor in a daily batch file.”

TO: “MTF pharmacies perform their own clinical review and the Government deems that the requirement for prior authorization for a drug has been satisfied if that drug has been dispensed at an MTF pharmacy, including medications dispensed in theater (See C.12.6). When adjudicating a claim at any point of service for a prescription requiring prior authorization, the Contractor shall review the profile for any MTF dispensings of the medication. If the medication has been dispensed by an MTF, the Contractor shall perform an administrative override to bypass the PA requirement and process the claim. This override shall be applicable to the dispensing of the medication at other points of service in alignment with benefit design rules as determined by the Pharmacy and Therapeutics Committee or business rules for claims processing.

The override does not apply to any ProDUR edits that the claim may generate and will be handled according to the applicable business rules for that claim.”

15) Section C, Paragraph C.10.3.1. Add the following to the end of the last bullet:

“The Contractor shall monitor undeliverable email and will not continue to send messages to known invalid email addresses. If the Contractor is notified that emails are being received by someone other than the intended recipient, the Contractor shall discontinue use of the email address until it has been verified by the beneficiary and corrected.”

16) Change paragraph number at C.10.4.7 to C.10.4.8.

17) ADD paragraph C.10.4.7. which reads:

“When a valid email address is available and the beneficiary has indicated a preference for electronic communications, the Contractor may issue any notification described under C.10.4 by email. Collection, maintenance and use of email addresses shall be in accordance with the Contractor’s plan described in

C.10.3.1”

18) Change paragraph C.11.3.3.

FROM: “The Contractor shall provide a daily report of reject overrides of MTF claims (CDRL D010).

The reports shall be broken out by MTF and sent to the pharmacy contact at each submitting MTF. A copy of the daily report shall also be provided to the TMA POC. The MTF pharmacy will have three (3) business days to correct these claims. The MTF may reverse the claim entirely or reverse and resubmit the corrected claim. After allowing three (3) business days for the MTF to correct any errors, the Contractor shall undertake retroactive claims correction in their system to correct the remaining errors and ensure that the claims reflect a paid status. This shall be completed within two (2) business days.”

TO: “The Contractor shall provide a daily report of MTF validity rejects (CDRL D010). The reports shall be broken out by MTF and sent to the pharmacy contact at each submitting MTF. A copy of the daily report shall also be provided to the TMA POC. The MTF pharmacy will have three (3) business days to correct these claims. The MTF may reverse the claim entirely or reverse and resubmit the corrected claim.

After allowing three (3) business days for the MTF to correct any errors, the Contractor shall undertake retroactive claims correction in their system to correct the remaining errors and ensure that the claims reflect a paid status. This shall be completed within two (2) business days. The Contractor shall continue to work the claim until it is posts to the profile, is reversed by the MTF, or the MTF notifies the Contractor to take no further action.”

19) ADD paragraph C.11.3.3.1. which reads:

“In the event that the Contractor’s resubmission of a previously rejected MTF claim results in a DUR

Interaction Severity Level 1, the Contractor shall contact the clinical staff at the submitting MTF by phone within one (1) hour. For all such situations, the Contractor shall keep a log that will be made available for the Government’s review upon request. At minimum, the log shall document the identifying information of the pharmacy, prescription and beneficiary and the dates and times of the original reject, the DUR and the call communicating the safety warning to the MTF.”

20) Delete the last sentence, “The CHDR interface uses the NCPDP 5.1 standard” under paragraph C.12.5.1.

21) Change paragraph C.12.5.2.

FROM: “The Contractor shall develop and maintain a real-time bidirectional interface to the CHDR via the B2B Gateway. CHDR will submit transactions to the Contractor for prescriptions dispensed to dual-eligible beneficiaries at VA pharmacies. The Contractor shall adjudicate these claims using the business rules specified by the Government. The Contractor shall support pharmacy-specific adjudication logic and configure adjudication rules for these transactions. The Contractor shall also identify any claims adjudicated under the TRICARE Pharmacy Benefit for VA dual-eligible beneficiaries and transmit these claims to the CHDR. ”

TO: “The Contractor shall send all Retail and MOP claims adjudicated under the TRICARE Pharmacy

Benefit to the CHDR. CHDR will submit transactions to the Contractor for prescriptions dispensed to dual-eligible beneficiaries at VA pharmacies.”

22) ADD paragraph C.12.5.3. which reads:

“The Contractor shall develop and maintain a real-time bidirectional interface to the CHDR via the B2B gateway. The CHDR interface uses the NCPDP 5.1 standard. The Contractor shall not generate TEDs for

CHDR claims.”

23) ADD paragraph C.12.5.4. which reads:

“The Contractor shall support specific adjudication rules for incoming CHDR transactions, including the following:

• The Contractor shall not check eligibility.

• No formulary edits or PA/MN rules will be applied.

• ProDUR will utilize VA-specific definitions and messaging the advisory information will be returned to the CHDR.

• There are no data integrity edits but claims that do not satisfy data requirements (missing or invalid data) can result in a rejected claims response with corresponding NCPDP reject

• There is no coordination of benefits for these claims.”

24) Change paragraph C.12.6.2.

FROM: “The Contractor shall develop and maintain an interface to TMDS. The Contractor shall retrieve

XML data files representing TMDS claims on a weekly basis, apply business rules provided by the

Government after award, and post those claims to PDTS.

• The files will contain data from two classes of source system: AHLTA-T and TC2. More information on these systems is available at http://dhims.health.mil/products/theater/ahlta-theater.aspx and http://dhims.health.mil/products/theater/tc2.aspx.

• Patients will be validated against DEERS prior to inclusion in the file. The Contractor shall not verify eligibility.

• The Contractor shall pre-edit the inbound data to modify the values to make them suitable for submission to PDTS and the Contractor’s real time adjudication and patient medication profile system.

• The Contractor shall log values that are mapped, inserted or calculated and make such logs available for review by the Government.”

TO: “The files will contain data from two classes of source system: AHLTA-T and TC2. More information on these systems is available at http://dhims.health.mil/products/theater/ahlta-theater.aspx and http://dhims.health.mil/products/theater/tc2.aspx.”

25) ADD paragraph C.12.6.3. which reads:

“The Contractor shall develop and maintain an interface to TMDS. The Contractor shall retrieve XML data files representing TMDS claims on a weekly basis, apply business rules provided by the Government after award, and post those claims to the patient profile on the contractor’s system and to PDTS. ”

26) ADD paragraph C.12.6.3.1. which reads:

“The Contractor shall pre-edit the inbound data to remove duplicate claims, those already posted to the profile, and aged claims, using a parameter defined by the government based on the date dispensed, currently claims over 365 days old. The Contractor shall also generate values for fields not included in the file and modify values of existing fields to make them suitable for adjudication using the NCPDP D.0 standard. Errors that must be corrected by the Contractor prior to adjudication include:

• Missing or Invalid NDC - TMDS claims contain a free text drug name but the NDC may be missing. At the Contractor’s request after award, the Government will provide a reference table to facilitate matching the drug name to the NDC, with ongoing maintenance of the table performed by the Contractor.

• Missing or Invalid DOB - Verify information using DMDC’s GIQD application and correct the claim.

• Missing or Invalid Gender - Verify information using DMDC’s GIQD application and correct the claim.

The Contractor shall apply their own methodology to reconcile any missing or invalid fields to allow the claim to post to the patient’s profile. Upon request, the TMA POC will answer questions and provide feedback during the transition period to assist the Contractor in refining their methodology.

TMDS claims are not received in real time and have already been dispensed. Therefore, all claims must be posted to the profile, excluding duplicates and aged claims. The Contractor shall not verify eligibility.

Standard edits performed as part of the adjudication process are not required and any edits the Contractor chooses to perform shall not impact the posting of the claim to the profile. The Contractor shall not reject

TMDS claims. TMDS claims will also be transmitted to PDTS.”

27) ADD paragraph C.12.6.3.2. which reads:

“The Contractor shall log values that are mapped, inserted or calculated, including the original value received on the file, and make such logs available for review by the Government. The Contractor will track volumes for claims received and posted and provide reporting to the Government (CDRL M240).”

28) Section C, Paragraph C.12.9.1. Add the following to the end of the paragraph:

“The Contractor shall also support profile inquiries from the MCSCs.The profile inquiry will be in the same format as those used by the MTFs (See C.6.7).”

29) Change paragraph C.19.1.4.

FROM: “During the period of performance, the Contractor shall be responsible for processing claims for dates of service prior to the start of pharmacy services under this contract. This includes initial submission of claims and any adjustments, corrections, or cancellations necessary for claims previously processed to completion by the outgoing Contractor, including “run-off” claims. Run-off for all processes not occurring in real-time, including but not limited to clinical reviews, paper claims, mail order prescription processing and beneficiary correspondence will occur on a date determined at the Transition meeting between the incoming and outgoing Contractors and the Government representatives.”

TO: “Run-off for all processes not occurring in real-time, including but not limited to clinical reviews, paper claims, mail order prescription processing and beneficiary correspondence will occur on a date determined at the Transition meeting between the incoming and outgoing Contractors and the Government representatives.”

30) Change paragraph C.19.4.1.

FROM: “The incoming Contractor shall receive batch files containing all retail, mail and MTF claims and prior authorizations and medical necessity determinations for the past two year period from the previous

Contractors. The exact mechanism for transferring these files shall be determined by mutual agreement between the current pharmacy Contractor and the previous Contractors. Prior to the start of pharmacy services under this contract, all data identified above for the prior two year period must be loaded into the pharmacy Contractor’s system for use in claims adjudication.”

TO: “The Contractor shall process transactions accurately and timely per contract standards at the start of pharmacy services, so the Contractor shall load all necessary information into its system before conclusion of the phase-in period.”

31) Change paragraph C.19.4.2.

FROM: “The outgoing Contractor shall also provide an OHI data file that the Contractor shall load into its system prior to the start of pharmacy services and maintain going forward. ”

TO: “The Contractor is responsible to receive the data files cited in C.4.10 in a manner that is mutually agreeable with the prior contractors. Once received, the Contractor shall maintain the OHI files at that point forward.”

D. Section F, DELIVERIES OR PERFORMANCE is revised as follows:

1) ADD the following Contract Data Requirements Lists (CDRLs) to paragraph F.2.4.

“M240 TMDS Claims Volume

D030 Contractor Payment – Check Issue Data”

2) Replace CDRL “W010” with the updated CDRL “W010”

3) Include attachment A to CDRL D020

E. Section G, CONTRACT ADMINISTRATION DATA is revised as follows:

1) Replace the word “fee” with “performance incentive” in the first sentence of paragraph G.5.8. Delete the word

“Fee” in the paragraph title.

2) Replace the phrase “incentive fee” with “performance incentive” in the first sentence of paragraph G.5.9.

3) Replace the phrase “incentive fees” with “performance incentive” in the first sentence of paragraph G.5.10.

4) Replace the phrase “incentive fees” with “performance incentive” in the first sentence of paragraph G.5.11.

Delete the word “Fee” in the paragraph title.

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

1) Replace the phrase “an incentive fee” with “a performance incentive” in the first sentence of the paragraph immediately following table H-1.

2) Replace the phrase “positive incentive fee” with “performance incentive” in the first sentence of paragraph

H.1.3.

3) Replace the phrase “incentive fee or negative incentive” with “performance incentive or guarantee recoupment calculation” in the last sentence of paragraph H.1.4.

4) Replace the phrase “incentive fee” with “performance incentive” and “negative incentive assessment” to

“guarantee recoupment” in the second sentence. Replace the phrase “an incentive fee” with “a performance incentive” in the second to last sentence of paragraph H.1.5. Delete the last sentence of H.1.5.

5) Replace the following phrases in paragraph H.2.1.1: Replace “an incentive fee” with “a performance incentive” in the first sentence; replace the phrase “an incentive fee” with “a performance incentive” in the seventh sentence; replace the phrase “an incentive fee” with “a performance incentive” in the eighth sentence; and replace the phrase “incentive fee” with “performance incentive” in the last sentence.

6) Replace the phrase “incentive fee” with “performance incentive” in the seventh sentence of paragraph H.2.1.3.

and replace the phrase “incentive fee” with “performance incentive” in the eighth sentence of paragraph

H.2.1.3.

7) Replace the phrase “an incentive fee” with “a performance incentive” in the first sentence of paragraph H.2.2.

and remove the word “fee” in the second to last sentence of H.2.2.

8) Remove the word “fee” in second sentence of paragraph H.2.2.2.

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

1) ADD the following Exhibit L-14 to paragraph L.12.

“L-14 DRAFT DoD Pharmacy Prospective Drug Utilization Review Parameters”

2) Replace the Exhibit L-4, DoD Benefit Design with the updated L-4, DoD Benefit Design

3) Replace the Exhibit L-5, DoD Formulary Restrictions and Limitations with the updated Exhibit L-5, DoD

Formulary Restrictions and Limitations

H. Exhibit A, Contract Data Requirements List, add M240 and D030.

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 09/27/2013

MATTHEW ANDERSON 303

matthew.anderson@tma.osd.mil

676-3754

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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

SECTION C

DESCRIPTION / SPECIFICATION / STATEMENT OF WORK

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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).

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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.4.10. Before the start of pharmacy services, the Government will provide (via previous contractors) batch files containing all retail, mail and MTF claims along with prior authorization and medical necessity determinations for the past two year period. The Government (via the outgoing contractor) will also provide an OHI data file.

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 103 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

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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.

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).

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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.

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 that may be specific to DoD and fall outside standard commercial practice, including Prescription Restriction Program restrictions and safety reviews established through the Uniform Formulary process. The Contractor shall support ProDUR business rules specific to the point of service.

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.

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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. During the period of performance, the Contractor shall be responsible for processing claims for dates of service prior to the start of pharmacy services under this contract. This includes initial submission of claims; and also any adjustments, corrections, or cancellations necessary for claims previously processed to completion by the outgoing Contractor. If/when the Contractor receives a claim to process that is greater than two years old and the Contractor did not receive relevant information during phase-in; the Contractor will do the necessary research to process the claim. All claims shall be processed according to benefit design and formulary restrictions in effect on the date of service.

C.6.1.17. For compounded medications, the Contractor shall support benefit design edits applied to each individual…