Amendment_0006.pdf

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

1. CONTRACT ID CODE PAGE OF PAGES

1 8

2. AMENDMENT/MODIFICATION NO.

3. EFFECTIVE DATE

02/14/2014

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

DEFENSE HEALTH AGENCY COD-AB

16401 E CENTRETECH PARKWAY

AURORA CO 80011-9066

MATTHEW ANDERSON 3036763754

DEPARTMENT OF DEFENSE

DEFENSE HEALTH AGENCY 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, X 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. This amendment hereby notifies all offerors within the competitive range that discussions are closed, and requests a final proposal revision (FPR). Offerors shall submit their FPR no later than 12:00PM, Mountain Standard Time, 21 February, 2014, to the Contracting Officer at the address in Block 7 of the SF33. This amendment also revises the agency name to reflect the Defense Health Agency; Block 7, 9, and 11 of the SF33; Section C, DESCRIPTION/SPECIFICATION /STATEMENT OF WORK; Section F, DELIVERIES OR PERFORMANCE; Section I, CONTRACT CLAUSES; Section L, INSTRUCTIONS, CONDITIONS AND NOTICES TO OFFERORS; Section M, EVALUATION FACTORS FOR AWARD; and replace EXHIBIT A.

(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

SEE SECTION L

mailto:bruce.mitterer@tma.osd.mil

AMENDMENT 0006, SOLICITATION HT9402-13-R-0001

B. Standard Form 33 is revised as follows:

1) Change block 7 of the SF 33:

FROM: “DEPARTMENT OF DEFENSE

TRICARE MANAGEMENT ACTIVITY COD

16401 E CENTRETECH PARKWAY

AURORA CO 80011-9066”

TO: “DEPARTMENT OF DEFENSE

DEFENSE HEALTH AGENCY COD-AB

16401 E CENTRETECH PARKWAY

AURORA CO 80011-9066”

2) Change block 9 of the SF 33:

FROM: “1200 PM MST local time 10/07/2013”

TO: “12:00 PM MST local time 02/21/2013”

3) Change block 11, table of contents on the Standard Form 33, to mark the box associated with “B SUPPLIES

OR SERVICES AND PRICE/COSTS”

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

1) Section C, Paragraph C.1.1.:

FROM: “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.”

TO: “TRICARE is the Department of Defense (DoD) health care program administered by the Defense

Health Agency, previously the TRICARE Management Activity (TMA) (any reference to “TRICARE

Management Activity” or “TMA” hereafter means “Defense Health Agency”) 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 eligible dependents, 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.”

2) Section C, Paragraph C.5.2 is revised to update the TRICARE Manuals. A summary of each change can be found on the Publications System Change Submittal page for the respective Manual changes at http://manuals.tricare.osd.mil/:

FROM: “o TRICARE Operations Manual (TOM) 6010.56-M dated February 1, 2008, at change 109 o TRICARE Policy Manual (TPM) 6010.57-M dated February 1, 2008, at change 99 o TRICARE Reimbursement Manual (TRM) 6010.58-M dated February 1, 2008, at change 89 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 54”

TO: “o TRICARE Operations Manual (TOM) 6010.56-M dated February 1, 2008, at change 117 o TRICARE Policy Manual (TPM) 6010.57-M dated February 1, 2008, at change 106 o TRICARE Reimbursement Manual (TRM) 6010.58-M dated February 1, 2008, at change 93 guidance in Chapter 1, Section 1.1, P3.4 & 3.5.1-3.5.1.7), at change 56”

3) The following revisions to paragraph C.7.1.13., and subset paragraphs, are made to further refine the requirements for the TRICARE For Life (TFL) pilot program. The quantities in Section B of this RFP are not revised and already reflect the quantities estimated for the TFL pilot. Section C.7.1.13. is revised:

FROM: “The Contractor shall support the mandatory mail pilot at the TMOP point of service as required in NDAA 2013, Section 716. This pilot will end on December 31, 2017 unless extended by Congress.

The pilot shall apply to TRICARE For Life (TFL) beneficiaries identified in DEERS when receiving medications identified on the Government’s mandatory mail drug list. The drug list includes select maintenance medications. The Government will provide an updated version of the list upon award and quarterly thereafter.”

TO: “The Contractor shall support the mandatory mail pilot at the TMOP point of service in accordance with TOM Chapter 18, Section 16. The Contractor shall provide a Summary and Savings Report for this pilot (CDRL M250).”

4) Change paragraph C.7.1.13.1.:

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

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

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

Government. Once the approved list of covered drugs is established, it will be modified by the Government, but not more than quarterly.

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

o Once a block is established, the Contractor will allow for two (2) refills at a retail pharmacy as a courtesy to give beneficiaries time to shift of their prescription to

MOP / MTF. Refill quantity will be limited to no more than a 30-day supply each.

o Subsequent to these two (2) refills, a retail pharmacy may request and the

Contractor will grant override(s) for an emergency refill of a prescription for a covered medication. All mandatory mail medications filled at a retail pharmacy will be subject to a 100% cost share.”

TO: “Under this pilot, TRICARE For Life (TFL) beneficiaries may only fill covered maintenance medications at TMOP or an MTF pharmacy. The Contractor will block refills, when dispensed at a retail network pharmacy, unless beneficiaries have received an approved one-time override or waiver from participation in the pilot. All medications covered under this pilot will be limited to a 30-day supply when dispensed at a retail network pharmacy.”

5) Change paragraph C.7.1.13.2.:

FROM: “When the Contractor processes a retail pharmacy claim for a beneficiary subject to this pilot, the

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

TO: “The Contractor shall support exceptions to the mandatory mail policy, which may be authorized for the following situations:

• A personal need, hardship, emergency, or other special circumstance requires use of retail pharmacy, as determined using Contractor-developed, Government-reviewed criteria.

• A TFL beneficiary residing in a nursing home or other long term care facility may request a waiver under the personal need, hardship or other circumstances exception.

Communication with the beneficiary, a relative or a caregiver is sufficient to establish residency in a nursing home. The Contractor shall apply the waiver in the patient profile which will allow a universal override for future retail dispensing.

• A medication is temporarily not available through TMOP.

• Prior Authorization has been approved for medication that requires frequent dose titration to achieve therapeutic levels.

• Prior Authorization has been approved for a beneficiary who is unable to have their medication delivered to their home.

The Contractor shall monitor and report the overrides granted under the pilot (CDRL M260).”

6) Change paragraph C.7.1.13.3.:

FROM: “The Contractor shall provide assistance to the beneficiary in transferring the prescription to an

MTF or TMOP, based on the beneficiary’s direction, as described under C.7.7.”

TO: “The Contractor shall support the promotion of retail to mail order conversion assistance and customer service inquiries concerning the pilot, including identifying medications on a beneficiary’s profile that are subject to this pilot and processing requested PAs and overrides.”

7) Change paragraph C.7.1.13.4.:

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

• After one (1) year, the beneficiary may choose to opt-out of mandatory mail for all covered drugs. The one (1) year period will be measured from the date on which the beneficiary’s first prescription for a covered prescription (previously filled at retail) was filled at the

MOP.

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

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

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

8) Change paragraph C.7.1.13.5.:

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

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

TO: “When the Contractor processes a retail network pharmacy claim for a beneficiary subject to this pilot, the Contractor will communicate program information to the beneficiary. The Contractor shall send a letter to the beneficiary by the end of the following week after each of the two (2) potential courtesy refills.

The letter shall be followed by an email or automated call. The letter shall remind the beneficiary of their options for obtaining future refills (refills at MTF, MOP or pay the full cost of the medication at a retail network pharmacy), provide contact information for the Contractor’s call center, and inform the beneficiary of the circumstances in which they may opt out of the pilot. In addition to the letter, the

Contractor shall also attempt a follow-up contact by phone or email.”

9) Change paragraph C.7.1.13.6.:

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

TO: “The Contractor shall contact a beneficiary via letter explaining the beneficiary’s options under the pilot in the following situations:

• The beneficiary has paid the full cost of their covered maintenance medication at a retail network pharmacy; or

• The beneficiary did not receive their medication at a retail pharmacy and did not subsequently contact the Contractor to obtain their prescription order through TMOP.”

10) Insert new paragraph C.7.1.13.7.:

INSERT: “After the two courtesy fills, the Contractor shall require beneficiaries to pay the full cost of prescriptions for covered maintenance medications when dispensed at a retail network pharmacy. When a beneficiary opts to pay full price for a covered medication at a retail network pharmacy, it is considered a non-covered service. A record of the dispensing shall be posted to PDTS. The Contractor will not reimburse in-network paper claims submitted by TFL beneficiaries who paid the full cost of a covered medication under this pilot unless otherwise authorized by the COR subsequent to a review.”

11) Insert new paragraph C.7.1.13.8.:

INSERT: “The Contractor shall monitor the availability of medications on the mandatory mail drug list at

TMOP. If the Contractor is unable to fill a medication subject to the mandatory mail policy at TMOP, the

Contractor shall have a process in place to contact the beneficiary to explain options available for filling the prescription, including issuing an override to allow for an additional courtesy fill of the medication at a retail pharmacy, if necessary, and instructions for how to reinitiate mail order service. When a previously unavailable medication becomes available at TMOP, the Contractor shall contact the beneficiary to attempt to recapture the medication at TMOP.”

12) Insert new paragraph C.7.1.13.9.:

INSERT: “The Contractor shall provide reporting on beneficiaries who opt out of the pilot (CDRL

M270).”

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

1) Insert the following into the list of CDRLs at section F.2.4. after “M240 TMDS Claims Volume” :

INSERT: “M250 TFL Pharmacy Pilot Summary and Savings Report

M260 TFL Pharmacy Pilot Override Report

M270 TFL Pharmacy Pilot Opt-Out Report”

E. Section I; CONTRACT CLAUSES is revised as follows:

1) Insert “before the contract expires” in the first sentence, after “30 days”, in clause 52.217-9 OPTION TO

EXTEND THE TERM OF THE CONTRACT (MAR 2000).

2) Insert the following clause:

INSERT: “52.232-39 UNENFORCEABILITY OF UNAUTHORIZED OBLIGATIONS (JUN 2013)

(Reference 32.706)”

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

1) Change paragraph L.3.3.:

FROM: “The estimated date of award will be in February 2014. See Section F.1.”

TO: “The estimated date of award will be in May 2014. See Section F.1.”

2) Insert the following into the table under paragraph L.6.1., “Volume I”, after the sixth bullet:

INSERT: “Minimum network size from C.6.5.1 (L.8.2.1.3).”

3) Change the table under paragraph L.6.4., “Technical Proposal”, page limit:

FROM: “70”

TO: “75”

4) Insert new paragraph L.6.7.1. for FPR instructions:

INSERT: “Offerors are required to submit their final proposal revision in accordance with the following instructions:

• Offerors are required to submit the entire completed Volume II, Volume III, and Volume IV of the proposal that contains the revisions made so that the proposal can be read in its totality.

• Offerors must submit a signed SF33 and completed section B in Volume I of their FPR. For the remainder of Volume 1, offeror’s may submit only portions of the proposal which have been revised.

• Any revisions made in the FPR must be marked with a change bar.

• With the FPR, Offerors shall submit a “cross matrix”, defined in this solicitation as a document which details the revisions made to the offeror’s original proposal. The cross matrix will only be used to facilitate the evaluation of the FPR, is not a part of the FPR, will not be evaluated, and is excluded from any page limitations. At a minimum, the cross matrix shall contain a table with the following information:

a. Section and page of the offeror’s original proposal where the revision is made,

b. The original proposal language of the section which is revised,

c. The revised proposal language.

• Offerors shall submit their FPR in accordance with section L.6.”

5) Change the first sentence of paragraph L.8.1.2:

FROM: “The technical proposal shall not exceed 70 pages inclusive of the exhibits, illustrations, attachments, flow diagrams, data dictionaries, figures, charts, and any other non-narrative inclusion.”

TO: “The technical proposal shall not exceed 75 pages inclusive of the exhibits, illustrations, attachments

(except the page containing C.6.5.1), flow diagrams, data dictionaries, figures, charts, and any other non-narrative inclusion.”

6) Change the number “70” to “75” and change the number “71” to “76” in the last sentence of paragraph L.8.1.2:

7) Delete the fourth sentence in paragraph L.8.2.1.1.1.:

DELETE: “Offerors shall describe its ability to process online coordination of benefits claims and pursue

OHI development in accordance with the TOM and TRM.”

8) Change paragraph L.8.2.1.3.:

FROM: “Offerors shall offer and guarantee minimum standards for the four network access measurements identified in C.6.5.1. To do so, offerors shall fill in the blanks at C.6.5.1 and include in the technical proposal. In no case may the offeror’s guaranteed percentage of beneficiaries within each of the three driving distance be less than 90% (i.e. driving distance of 90% of the beneficiaries). In no case may the offeror’s guaranteed network size be less than 50,000 retail pharmacies.”

TO: “Offerors shall offer and guarantee minimum standards for the four network access measurements identified in C.6.5.1. To do so, offerors shall return the actual page from the solicitation that contains

C.6.5.1 with the blanks in C.6.5.1 filled in with the requested information. This original page shall be included in Volume 1, Executed Offer. A copy of this page shall also be attached to the technical proposal and referenced in the technical proposal. This page is not included in the page count. In no case may the offeror’s guaranteed percentage of beneficiaries within each of the three driving distance be less than 90% (i.e. driving distance of 90% of the beneficiaries). In no case may the offeror’s guaranteed network size be less than 50,000 retail pharmacies. Further, any information in an offeror’s proposal that is contrary to the information required by C.6.5.1. will not be evaluated.

9) Change the number “70” to “75” in section L.8.2.1.3.2.:

10) Change the first sentence of the second paragraph at L.8.2.1.3.2.:

FROM: “Offerors shall describe their strategy and capabilities for developing, implementing, and maintaining the required interfaces.”

TO: “Offerors shall describe their strategy and capabilities for developing, implementing, and maintaining the required interfaces with MTFs, DEERS, PDTS, CHDR and TMDS.”

11) Change the first sentence of the paragraph at L.8.2.2.3.:

FROM: “Offerors shall provide a solution for replenishment.”

TO: “Offerors shall provide a solution for replenishment, to include specialty pharmaceuticals.”

12) Delete the following at the end of the first sentence of the paragraph at section L.9.1.3.

DELETE: “in lieu of the maximum 15 page narrative”

13) Delete last sentence of the paragraph at section L.9.1.3.

14) Insert the following sentence after the second sentence at L.9.2.:

“Should an offeror, or a critical subcontractor, not perform prescription processing for any commercial clients, offerors may submit a description of its five (5) largest commercial clients, measured by total number of beneficiaries, for that offeror or its critical subcontractors.”

15) Insert the following sentence after the second sentence at L.9.3.:

“Should an offeror, or a critical subcontractor, not perform prescription processing for any federal and/or state Government clients, offerors may submit a description of its five (5) largest federal and/or state

Government contracts, measured by total number of beneficiaries, for that offeror or its critical subcontractors.”

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

16) Change the first sentence at paragraph M.3.2.2.:

FROM: “The offeror’s proposal will be evaluated on its ability to support a scalable approach for processing paper claims, coordination of benefits, non-network claims, batch claims, OHI development, and assignment of benefit claims.”

TO: “The offeror’s proposal will be evaluated on its ability to support a scalable approach for processing paper claims, electronic claims, coordination of benefits, non-network claims, batch claims, OHI development, and assignment of benefit claims.”

H. Exhibit A is removed and replaced with the attached revised Exhibit A.

I. Exhibit L-4, DOD BENEFIT DESIGN is removed and replaced with the attached revised L-4, DOD BENEFIT

DESIGN.

J. Exhibit L-8, DRAFT TRICARE FOR LIFE (TFL) MANDATORY MAIL DRUG LIST is removed and replaced with the attached revised L-8, DRAFT TRICARE FOR LIFE (TFL) MANDATORY MAIL DRUG LIST.

K. 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.

Sections, exhibits, and attachments 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

DEFENSE HEALTH AGENCY COD-AB

16401 E CENTRETECH PARKWAY

AURORA CO 80011-9066

12:00PM MST 02/21/2014

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

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MAnderson Typewritten Text x

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Typewritten Text

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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) (any reference to “TRICARE Management Activity” or “TMA” hereafter means “Defense Health Agency”) 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 117 o TRICARE Policy Manual (TPM) 6010.57-M dated February 1, 2008, at change 106 o TRICARE Reimbursement Manual (TRM) 6010.58-M dated February 1, 2008, at change guidance in Chapter 1, Section 1.1, P3.4 & 3.5.1-3.5.1.7), at change 56

H94002-13-R-0001 32

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 ingredient in the compound segment of the National Council for Prescription Drug Programs

(NCPDP) D.0 transaction standard.

C.6.1.18. The Contractor shall provide the Government with licenses to Medispan and First Data Bank for purposes of calculating the Retail Network Cost Control Incentive.

C.6.1.19. The Contractor shall submit a TED record for all paid claims and clinical reviews conducted under this contract (See C.15.2).

C.6.2. Other Health Insurance

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

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

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

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

Government on OHI development (CDRL Q190).

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

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

C.6.3. Retail Network Claims

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

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

Islands, American Samoa and Guam.

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

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

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

C.6.3.4. The Contractor shall complete…