DRAFT RFP Section C

TPharm4 Draft Statement of Work Table of Contents

DRAFT 31 July 2012 Page 38

TPharm4 Statement of Work

C.1. Program Description

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. TRICARE is authorized under 32 CFR 199.21 and Chapter 55 of Title 10 USC Section 1074g.

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 Continental United States and overseas. 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.

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 available in all 50 states and the District of Columbia, Guam, Puerto Rico, American Samoa, the Northern Mariana Islands and the U.S. Virgin Islands.

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 Committee (P&T) 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 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). In addition to TRICARE beneficiaries, certain patients of the Department of Veterans Affairs (DVA) may also be eligible to have prescriptions filled at one or more points of service under the TRICARE Pharmacy Program.

DVA patients will be eligible to have prescriptions filled at TRICARE retail network pharmacies in circumstances when the patient requires immediate therapy and there is no DVA pharmacy available to provide the medication. DVA beneficiaries are not eligible to obtain prescriptions from the TRICARE Mail Order Pharmacy or from retail pharmacies that are not part of the TRICARE retail pharmacy network.

Under this TRICARE Pharmacy (TPharm4) contract the contractor will perform pharmacy benefits management functions, including the following: perform claims adjudication, administer a retail pharmacy network, operate a Mail Order Pharmacy (MOP), provide clinical services for specialty pharmaceuticals, process direct member reimbursements for claims filled at retail network and non-network pharmacies, administer paper claims, perform clinical reviews and provide beneficiary and pharmacy support services. The contractor shall transmit all claim information to the Pharmacy Data Transaction Service (PDTS), the government’s designated data warehouse.

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 contract 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. The contractor will issue payment using Government funds to pay for each TRICARE prescription dispensed at retail network pharmacies after receiving the Government’s verification of the individual beneficiary's eligibility and authorization for payment. Therefore, the Government will be acquiring covered drugs and procuring them for the use of the Federal Government in support of this contract with Government funds.

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.

4. Provide effective contract management 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 under Section J.

C.4. Government-Furnished Information

The contractor shall connect to the Defense Enrollment Eligibility Reporting System (DEERS), according to the requirements established in Section C.6.1 and the TRICARE Systems Manual.

The government will provide licenses for the contractor 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).

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).

The government shall provide the contractor with a pricing file to be used for adjudicating MTF claims.

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

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.

C.5. Requirement Documents

The following documents are hereby incorporated by reference and made a part of the contract:

· TRICARE Manuals. Additionally, the following TRICARE manuals are incorporated by reference:

· TRICARE Policy Manual (TPM) 6010.57-M dtd February 1, 2008, at change 70

· TRICARE Reimbursement Manual (TRM) 6010.58-M dtd February 1, 2008, at change 69

· TRICARE Systems Manual (TSM) 7950.2-M dtd February 1, 2008, with all (except the DIACAP guidance in Chapter 1, Section 1.1, ¶3.4 & 3.5.1 – 3.5.1.7) at change 40

· TRICARE Operations Manual (TOM) 6010.56-M dated February 1, 2008, at change 80

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

The contractor shall provide mail order pharmacy (including specialty pharmacy) services, a retail pharmacy network, claims adjudication for MTF claims and related Pharmacy Benefit Management (PBM) services as specified herein.

The contractor shall accept and process claims submitted by retail network pharmacies, the TRICARE mail order pharmacy, MTF pharmacies, or by beneficiaries for direct reimbursement.

The contractor shall provide 24x7 claims processing, excluding downtimes for scheduled maintenance. The contractor’s system shall be available 99.5% of the net operating time. The system is considered to be available when the failure rate for claims is less than 25%.

For TRICARE beneficiaries, the contractor shall interface with the Defense Enrollment & Eligibility Reporting System (DEERS) to verify eligibility, update the Catastrophic Cap and Deductible Database (CCDD) file, and check for Other Health Insurance (OHI). The contractor shall use the applications described in the TRICARE Operations and Systems Manuals to support this process. The contractor shall use the beneficiary’s catastrophic cap and deductible status to apply the correct co-payment and deductible. The contractor will then update the CCDD file in accordance with the TRICARE Systems Manual. The contractor shall not authorize payment for a prescription prior to verifying eligibility. The contractor shall minimize unnecessary queries to DEERS for transactions not authorizing payment and as a resulted of timed-out transactions. During contract Phase-In, the contractor shall provide estimates to DMDC on projected DEERS query volume over the period of performance and shall investigate and revise these estimates as necessary when they differ significantly from actual volumes reported by DEERs. The contractor shall schedule maintenance windows to coincide with published maintenance windows for DEERS. The contractor shall participate in regular integration testing meetings as directed by the government throughout the duration of the contract, with a minimum frequency of once per week up to a maximum of daily.

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 TRICARE Systems Manual and the contractor’s system shall link the identifier transmitted by the pharmacy with the DEERS ID.

The contractor shall conduct Prospective Drug Utilization Review (ProDUR) on dispensing transactions submitted by the three points of service: MTF, Mail-Order, and Retail pharmacies. The ProDUR shall evaluate the new prescription against the patient’s current drug regimen and return appropriate clinical warnings. The contractor shall also perform other real-time edits (e.g., Sole Provider Rx Restriction Program restrictions). ProDUR Business Rules specific to MTFs are noted in Section C.12.3.

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.

Claims for infused and injectable pharmaceutical agents shall be provided in accordance with the TRICARE Policy Manual, Chapter 8, Section 9.1.

Co-payments shall be charged to beneficiaries in accordance with the TRICARE Reimbursement Manual, 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. Treasurer) 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.

The contractor shall provide the government with licenses to Medispan and First Data Bank for purposes of calculating the Retail Network Guarantee incentive described in H.1.2.

The contractor shall maintain current claims data for all TRICARE prescriptions.

The contractor shall submit a TRICARE Encounter Data (TED) record for all paid claims and clinical reviews conducted under this contract. TEDs shall be processed in accordance with the TRICARE Systems Manual.

C.6.1.1. Other Health Insurance

The contractor shall implement processes to maximize the identification of Other Health Insurance (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 or pharmaceutical manufacturers, the contractor shall investigate and develop OHI records in accordance with TRICARE Operations Manual, Chapter 23, Section 3. 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 TRICARE Systems Manual.

A beneficiary with OHI cannot use the MOP, 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 MOP, 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.6.2. Retail Network Claims

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.

Retail claims for pharmaceutical agents and diabetic supplies will be limited by requirements under 10 USC 1074 g.(f), 32 CFR 199.21 and other applicable regulations. 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/supply or the shift of their prescription to the mail order pharmacy.

Pharmaceuticals agents and diabetic supplies that are restricted at retail and their respective implementation dates are published at http://www.tricare.mil/pharmacy/PT_Cmte/default.htm.

Claims received for pharmaceutical agents and diabetic supplies 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 TRICARE Operations Manual, Chapter 8, Section 2. Network pharmacies may submit claims for covered supply items using the NDC numbers or NDC-like numbers assigned to them.

The contractor shall complete real-time, on-line coordination of benefits (COB) in accordance with National Council for Prescription Drug Programs (NCPDP) D.0 standards (or most current version) for those claims filled in retail network pharmacies where OHI has been identified, to include Medicare Part D claims. The Government will provide the COB and Medicare Part D billing transaction segments to include the required values. The contractor is required to track Medicare Part D true out-of-pocket expenses (TROOP) and total drug expenditures for each TRICARE beneficiary who is also enrolled in Medicare Part D. The contractor shall provide this information to the Centers for Medicare & Medicaid Services (CMS) designated TROOP facilitator. Claims shall be reimbursed in accordance with the TRICARE Reimbursement Manual, Chapter 4.

Claims for prescriptions filled but not dispensed (non-compliant) shall be reversed within ten calendar days of the date the original claim was submitted to the maximum extent possible. Reversals processed more than ten calendar days after the date the original claim was submitted will require an adjusted or cancelled TED record. The contractor will not be eligible for cancellation fees unless submitted in accordance with the TRICARE Systems Manual.

The contractor shall process batch claims in the most current NCPDP batch format. The contractor may receive batch claims from a variety of sources (e.g., State Medicaid agencies, clearinghouses, DVA) and the contractor shall receive process these claims regardless of the electronic media (e.g., CD ROM, tapes) through which they are submitted.

C.6.2.1. Non-Electronic Claims

The contractor shall process non-electronic claims as described in TRICARE Operations Manual, Chapter 23, Section 3, Paragraph 1.2.

The contractor shall accept direct member reimbursement (DMR) claims submitted using claim forms specified in TRICARE Operations Manual, Chapter 8, Section 1, Paragraph 3.1. Upon request, the contractor shall mail the current version of the DD 2642 claim form to beneficiaries. The contractor shall also make the form available for downloading by linking its TPharm web site to the DD 2642 on the TMA website. DMR claims, also known as paper claims, for non-network pharmacy services shall be reimbursed in accordance with the TRICARE Reimbursement Manual, Chapter 1, Section 15, minus applicable co-payments and deductibles. The contractor shall process these claims, by prescription, using the most current NCPDP format.

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

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

· 99% of paper claims shall be processed to completion within 28 calendar days of receipt.

· 100% of paper claims shall be processed to completion within 42 calendar days of receipt.

For denied paper claims, notification to the beneficiary must be in writing, and must explain why the order or claim was denied, detailing the beneficiary's appeal rights. Each prescription processed will generate an individual TRICARE Encounter Data (TED) record in accordance with the TRICARE Systems Manual.

C.6.2.2. Retail Network Pharmacy Services for DVA Beneficiaries

DVA beneficiaries will be eligible to have prescriptions filled at TRICARE retail network pharmacies in circumstances when the patient requires immediate therapy and there is no DVA pharmacy available to provide the medication. This occurs with outlying Community Based Outpatient Clinics (CBOCs) and at off hours, where a supply of medication is needed to initiate therapy until the remainder of therapy can be mailed from the DVA’s Consolidated Mail Outpatient Pharmacy (CMOP). DVA beneficiaries are only authorized the dispensing of emergent need medications when prescribed on a DVA prescription blank stating “Authorized for Emergent Need.” DVA beneficiaries are not eligible to obtain prescriptions from the TRICARE Mail Order Pharmacy or from retail pharmacies that are not part of the TRICARE retail pharmacy network.

The contractor shall utilize the DVA’s eligibility database to verify eligibility prior to authorizing retail network pharmacies to dispense prescriptions to DVA beneficiaries. The contractor shall ensure that network pharmacies verify that the prescription is on a DVA prescription blank stating “Authorized for Emergent Need.” If a DVA beneficiary has questions about eligibility for services, the contractor shall tell the beneficiary to contact their primary care provider at the DVA facility.

The contractor shall bear the cost and burden of establishing the communications interface with DVA’s eligibility database and shall ensure that the interface meets DVA security requirements. Eligibility queries will utilize NCPDP standards as required under the Health Insurance Portability and Accountability Act (HIPAA).

The contractor shall authorize network pharmacies to fill prescriptions for DVA beneficiaries for any pharmaceutical agent that is covered under the TRICARE retail pharmacy benefit regardless of the status of the pharmaceutical agent on the DoD Uniform Formulary. The status of a pharmaceutical agent on the DoD Uniform Formulary, the DoD co-payment requirements, the DoD prior authorization requirements, the DoD Medical Necessity Determination requirements, and DoD recoupment requirements do not apply to prescriptions filled for DVA beneficiaries. The contractor shall ensure that network pharmacies do not collect co-payments from DVA beneficiaries.

The contractor shall apply the DoD quantity limits and the DoD mandatory generic policy to prescriptions filled for DVA beneficiaries, except that Coumadin® will be dispensed for prescriptions for warfarin sodium, Dilantin® will be dispensed for prescriptions for phenytoin sodium, Synthroid® will be dispensed for prescriptions for levothyroxine and Cordarone® will be dispensed for prescriptions for amiodarone.

The contractor shall deny paper claims received for prescriptions filled for DVA beneficiaries at non-network pharmacies. If a non-network retail pharmacy fills a prescription for a DVA beneficiary, the DVA beneficiary is responsible for payment to the pharmacy in full.

The contractor shall not mail TPharm educational materials to DVA beneficiaries, unless specifically authorized to do so by the DVA through the TPharm Contracting Officer.

C.6.3. Retail Pharmacy Network

The contractor shall establish and maintain a retail pharmacy network throughout the 50 United States, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Northern Mariana Islands, and Guam.

The contractor shall provide network retail pharmacy services in American Samoa, when there are pharmacies in American Samoa with NCPDP numbers which are then eligible to become TRICARE network pharmacies. The contractor shall establish a pharmacy network which meets the following minimum access standards, referring to definitions provided in TRICARE Operations Manual, Appendix B:

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

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

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

All network pharmacies shall be fully licensed in accordance with applicable Federal and State laws, and have a current NCPDP number. Pharmacies providing pharmaceuticals solely through Internet or mail order pharmacies shall not be included in the retail network.

Retail pharmacies who offer to mail prescriptions to beneficiaries as part of their business may be included in the network subject to the retail pharmacy specifications listed herein.

The contractor is required to adjudicate current and future claims received from DVA, Public Health Service (PHS), and Indian Health Service (IHS) pharmacies identified by the Government. Reimbursement for pharmaceuticals dispensed through these pharmacies will be directed by the Government. These Pharmacies will be reimbursed at acquisition cost plus a Government negotiated dispensing fee. These pharmacies shall not be included in the measuring of performance under the network access standards nor in the calculation of the guaranteed reimbursement rates.

The contractor shall ensure that network pharmacies have procedures to reasonably assess the validity of prescriptions ordered by telephone.

At a minimum, the retail pharmacies shall provide TRICARE beneficiaries the same quality of services provided to beneficiaries of other commercial clients to the extent allowed by Federal regulation and this contract.

The contractor shall ensure that all pharmacies document the receipt of the medication by the beneficiary or the individual authorized by the beneficiary, in accordance with all applicable State and Federal Laws.

C.6.3.1. Retail Network Changes

When pharmacies are removed from the contractor’s retail pharmacy network, the contractor shall notify beneficiaries who have filled prescriptions at the impacted pharmacies during the previous 6 months.

To minimize the impact of network changes, the contractor shall perform the following steps.

No later than 60 days prior to the effective date of the change, the contractor shall:

· Provide the government with the names of all pharmacies selected for removal from the network.

· Identify the number of DoD beneficiaries who have filled prescriptions at these pharmacies within the previous 6 months by the following categories:

· Specialty Medications

· Limited Distribution Medications

· Hemophilia Medications

· Other Non-Specialty

· Provide a plan of action detailing how impacted DoD beneficiaries will be notified of the change. The plan shall include, at minimum, the following elements:

· Advance notification to all beneficiaries who have filled prescriptions at the impacted pharmacies.

· Outreach by letter, phone and/or other electronic to beneficiaries utilizing specialty, limited distribution and hemophilia medications.

· Provide the government with a sample of all beneficiary correspondence related to the change in the network for review, no later than 30 days prior to the effective date of the change

· Provide reporting on the contractor’s success in shifting beneficiaries to network pharmacies or the MOP.

For purposes of the report, a successful transfer will be defined as documentation that a new claim for the specialty medication has been submitted by an approved network pharmacy, mail order pharmacy, or Military Treatment Facility (MTF); a review by a pharmacist has determined that a similar therapeutic entity has been substituted; or based on the therapeutic entity itself, it can be reasonably assumed that therapy has been completed.

When preparing the report, the contractor shall evaluate the effectiveness of its action in reach all beneficiaries and make changes to the plan as necessary to prevent disruption of therapy for the maximum number of beneficiaries possible.

At 180 days after the effective date of the change, the contractor shall provide a final report of all beneficiaries that have not been successfully transferred and a full accounting of all efforts made to contact that patient, including dates attempted and contact methods employed.

C.6.4. MTF Claims

The TPharm contractor shall be connected to the DoD MHS electronic medical record, currently Composite Health Care System (CHCS) pharmacy/AHLTA, as described in Section C.12.

CHCS pharmacy/AHLTA first verifies MHS beneficiary eligibility through an interactive check with the DEERS, then forwards the prescription data to the TPharm contractor for ProDUR before filling the prescription. The TPharm contractor shall return ProDUR response information to the CHCS host, which interprets it and provides the necessary information to the submitting pharmacy. The TPharm contractor shall receive dispensing transactions and profile inquiry transactions from all MTFs and MTF pharmacies. The TPharm contractor shall perform ProDUR on the inbound dispensing transactions and returns the requested data on profile inquiries. All traffic shall be logged and dispensing transactions are transmitted to the data warehouse.

The contractor shall support messaging to the MTF that varies from that used by the commercial network.

C.7. Mail Order Pharmacy

The contractor shall support MOP registration by a variety of means, including but not limited to submissions in writing, via telephone, or via the contractor’s web site.

The contractor shall accept prescription orders at the mail order pharmacy by written (original or facsimile), electronic (supporting digital signature including e-prescribing), or telephonic submission. The contractor shall have procedures in place to reasonably assess the validity of prescription orders submitted by telephone.

MOP prescription processing and written notification of denied orders shall meet the following minimum requirements:

· Mail order prescriptions shall be shipped, returned, or denied within an average of 5 days from receipt, date stamped in accordance with TRICARE Operations Manual Chapter 8, Section 1.

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

· In the event the contractor fails to mail any prescription that did not require clarification or intervention within 7 days, the contractor shall automatically provide next day delivery service at no additional charge to the beneficiary.

For each MOP prescription received requiring clarification or intervention, the contractor shall contact the prescriber as appropriate. If the contractor is unable to obtain a response from a prescriber, they shall contact the beneficiary telephonically or by electronic means, based on the beneficiary’s indicated preferences. The contractor shall provide order status and request beneficiary direction to either hold the prescription for fill or to cancel. The beneficiary shall have no less than 72 hours to provide a response before the prescription is returned. The contractor shall document all calls, and the beneficiary’s direction. The contractor shall not return a prescription without first attempting to contact the beneficiary.

For beneficiaries in deployed theaters of operation, the contractor shall dispense medications as indicated in section C.7.8.

For beneficiaries not in deployed theatres of operation the contractor shall provide notification by telephone or other electronic means, based on beneficiary preference, of prescriptions received, placed in a pended status, and the anticipated processing date for each.

The contractor shall pend prescriptions in lieu of rejecting early submissions.

For all denied mail order prescriptions, notification to the beneficiary must be in writing explaining why the order was denied and detailing the beneficiary’s appeal rights.

For beneficiaries receiving prescription medications through the MOP, the contractor shall provide 24/7 access to a pharmacist by phone.

Tracking and dispensing procedures shall be in the accordance with Federal and State law. The Contractor shall not collect sales tax on prescriptions dispensed by the mail order pharmacy.

Dispensed ingredients shall be priced on the TED record at the burdened Unit of Measure Price from the Managed Care Pricing File (MCPF) provided by the Defense Logistics Agency (DLA). See Section C.7.11 for more information.

C.7.1. Mail Order Pharmacy Accounts

For MOP prescription orders, the contractor shall allow beneficiaries to provide a credit card for the co-payment amount. The contractor shall establish individual accounts for family members, and shall allow for more than one credit card to be on record for collection purposes. The contractor shall ensure that if a beneficiary overpays a co-payment amount, the beneficiary is notified that the excess has been credited to the beneficiary’s account for future prescriptions, or the overpayment is refunded to the beneficiary along with the explanation of the refund, whichever the beneficiary prefers.

As a result of its own business judgment and at its own risk, the contractor may choose to extend credit to beneficiaries so that when an insufficient co-payment is received, the contractor may fulfill the prescription order up to the amount of the contractor established credit limit and credit aging parameters. As the contractor is not acting as an agent of the Government in extending credit to beneficiaries, none of the recoupment procedures set forth in this contract or the TRICARE manuals shall be available to the contractor to collect beneficiary co-payments. Likewise, any uncollected debts from beneficiaries resulting from the extension of credit are not reimbursable under this contract. If the contractor does not extend credit or the beneficiary has exceeded the contractor’s established credit parameters, the contractor shall return the prescription to the beneficiary and notify the beneficiary of the correct co-payment amount required

C.7.2. Mailing Prescriptions

MOP prescription orders shall only be mailed to beneficiaries living in the 50 United States, the District of Columbia, Puerto Rico, U.S. Virgin Islands, Northern Mariana Islands, American Samoa and Guam; to beneficiaries with an Army Post Office (APO), Fleet Post Office (FPO), or U.S. Embassy address; and to troops in deployed theatres of operation. Beneficiaries in deployed theatres of operation will be identified by the Government.

MOP prescriptions shall be shipped or mailed postage paid to the beneficiary in a manner which provides, at a minimum, a delivery time equivalent to first class U.S. Mail.

Upon request by the beneficiary, the contractor shall provide next day delivery services to beneficiaries residing in the continental United States (CONUS). The contractor may charge the beneficiary for the additional shipping cost in accordance with the most favorable shipping rate available to the contractor.

The contractor shall ship medications care of (c/o) to the beneficiary’s health care provider’s office, if requested by the beneficiary.

The contractor shall be responsible for all medications dispensed by the contractor up to the point of delivery to the beneficiary or to the alternate delivery location designated by the beneficiary. The contractor shall allow 12 days from the original ship date for the beneficiary to receive their order. Beginning 12 days after the ship date, the contractor shall reship the order within 3 days of receiving notification from the beneficiary that their order has not been received. A beneficiary shall have up to 45 days from the original ship date to report that an order was not received and request a replacement with no additional co-payment. This shall be extended to 60 days for prescriptions sent using an APO, FPO or U.S. Embassy address. The contractor shall not receive an administrative fee or replenishment for replacement shipments.

The contractor shall comply with U.S., Military and U.S. Embassy Postal Service regulations.

The contractor shall include a pre-addressed envelope with each order shipped so the beneficiary may order refills or new prescriptions.

C.7.3. Partial Shipments

When directed by the government, the contract will provide partial shipments of high cost medications if the days’ supply called for on the prescription exceeds 30 days. The full co-payment will be collected on the first partial shipment. Subsequent partial shipments will have no co-payment assessed until the full quantity of the prescription has been dispensed or until the prescription has expired. The contractor shall document the receipt of the copay and all subsequent shipment covered by that co-payment.

The contractor shall follow guidelines established by P&T, provided at http://www.tricare.mil/pharmacyiPTCmte/default.htm when dispensing partial fills through the mail order pharmacy.

C.7.4. Compounded Medications

Before dispensing any compounded medication through the MOP, the contractor shall verify that all supplies and ingredients required to prepare the compound are available for replenishment from the National Prime Vendor (NPV), as described in C.7.11. In the event that any required products are not available, the contractor shall return the prescription to the beneficiary.

C.7.5. Error Reporting

The contractor shall provide a report on all defects and errors at the MOP. For purposes of this report, the Government defines a medical error according to the National Coordinating Council for Medication Error Reporting & Prevention (NCC-MERP): “Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the health care professional, patient or consumer.“ Examples include, but are not limited to:

· Lost or damaged prescriptions [discovered] upon receipt, resulting in delay in processing and/or increased difficulty in transcription;

· Prescriptions entered into the incorrect patient’s profile, transcribing the wrong drug or dose, or directions [sig], into the patient’s profiles;

· Failing to correctly enter all elements of a prescription, e.g., refills, such that the patient may not correctly receive the correct duration of therapy; or events that may trigger an allergy or drug-drug interaction, dosed incorrectly, wrong quantity transcribed, etc;

· Incorrect quantity dispensed, broken medications, label, bottle or packing defects, improper storage or shipping.

C.7.6. Prescription Transfers from Retail

At the beneficiary’s request, the contractor shall contact the provider to obtain a new prescription to be filled by the MOP or the beneficiary’s designated MTF Pharmacy. The contractor shall offer both points of service as an option to the beneficiary to transfer their medications.

For each prescription transferred from a retail pharmacy to the MOP or MTF pharmacy, the contractor shall receive an incentive fee. The contractor must have a record of the prescription being filled at retail within the prior 60 days and must have contacted the provider to obtain a new prescription for the mail order pharmacy or MTF pharmacy to be eligible for the incentive payment. Upon request, the contractor shall provide documentation to the government that both of these criteria have been met. 100% of all transfers shall be completed within 21 days from beneficiary authorization.

C.7.7. Mandatory Generic Program

The TRICARE pharmacy program requires mandatory generic substitution. The contractor will use best commercial practices to maximize generic substitution, including attempts to convert Dispense as Written (DAW) prescriptions. Upon receipt of a DAW prescription for a brand name product for which a generic equivalent is available, the contractor shall contact the prescriber to change the prescription to a generic equivalent. If the prescriber refuses to switch, then the prescription shall be processed according to government-approved prior authorization criteria, as described in C.9.1. If the prior authorization is denied, the prescription shall be returned to the beneficiary. If the contractor cannot contact the prescriber, the contractor shall call the beneficiary, notify them that their prescription will be returned, and the reason why. For all denied mail order prescriptions, the contractor must also provide notification to the beneficiary in writing explaining why the order was denied and detailing the beneficiary's appeal rights.

In instances when the Government has determined it to be benefical and provided direction, the contractor may dispense brand in lieu of generic without a prior authorization.

The contractor shall identify Brand over Generic prior authorizations at retail and mail in its reporting of Clinical Reviews.

C.7.8. MTF Prescriptions: Mail Fulfillment

The contractor shall provide a modified dispensing operation through the MOP in support of MTF pharmacies. The government will establish the list of drugs to be supported under this requirement. MTF pharmacies will transmit eligible prescription orders to the contractor for dispensing and shipping. Under this program, the contractor will dispense the requested prescription using the information provided on the request. The contractor shall not perform checks for eligibility or ProDUR. The contractor will not collect a copayment for these prescriptions. All prescription orders shall be shipped to the beneficiary within 7 days of receipt using the address provided on the request and an electronic response sent to the MTF with the shipment tracking information for the prescription. In the event that the contractor is unable to dispense the medication, the contractor shall return a message to the MTF stating that the prescription could not be filled with an explanation This notification shall be sent to the MTF as soon as the contractor is aware that they will not be able to fill the medication but no later than 7 days after receipt. The MTF retains ownership of all prescriptions filled through this modified dispensing operation and will provide all customer service related to the prescription. The contractor’s system shall identify all prescriptions it dispenses through its mail order facility that originated from an MTF and transmit that information to the data warehouse.

All medications dispensed under this requirement shall identify the MTF as the dispensing pharmacy on the prescription label, subject to state board of pharmacy requirements, and shall provide the address and phone number of that MTF. The contractor shall not provide customer support services to the beneficiary for MTF prescriptions fulfilled through the MOP. The contractor shall not generate a TED for these prescriptions.

The standard replenishment process, described in C.7.9 will be used for drugs dispensed under this requirement.

The contractor shall develop a drug file based on the government’s drug list that will map to the MTF’s prescribed medication to determine the exact medication dispensed by the MOP. The contractor shall provide ongoing support to the MTFs for this mapping file and all other aspects of this program, as described in C.10.2.

Medications dispensed through this program shall be included in all applicable mail order pharmacy reporting, where they will be separately broken out and identified.

Prescriptions dispensed shall meet the following standards:

· 100% of MTF prescriptions fulfilled by the MOP shall be shipped or returned to the MTF within 7 calendar days of receipt, measured monthly.

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

C.7.9. Specialty Pharmacy Services

Specialty pharmaceuticals are high-cost injectable, infused, oral or inhaled drugs that are generally more complex to distribute, administer and monitor than traditional drugs. The contractor shall provide specialty pharmaceuticals through the mail order and retail pharmacy venues. The contractor shall operate programs to maximize the extent to which beneficiaries obtain specialty pharmaceuticals from mail order rather than from retail pharmacies.

Recognizing that in the retail venue specialty or limited distribution drugs are frequently shipped to beneficiaries from centralized locations, the DoD designates specialty pharmacies owned, affiliated, or contracted by the contractor as “DoD specialty mail order” outlets subject to federal ceiling pricing and mail order replenishment requirements outlined in Section C.7.9 of this contract offering.

The contractor shall ensure that beneficiaries have access to pharmaceuticals that are subject to limited distribution channels established by the pharmaceutical manufacturer and/or the Food and Drug Administration.

The contractor shall provide a dedicated toll free number for beneficiaries and providers to call for assistance relating to specialty pharmaceuticals and services. Hours of operation shall be 8 a.m. to 9 p.m. (ET) at a minimum. A Pharmacist shall be accessible 24 hours a day/7 days a week in support of the mail order pharmacy and clinical services program.

At the government’s direction, the contractor shall provide data to and accept data from the regional medical contractors (MCSCs) and the government. The contractor shall also collaborate with the medical contractors and the government in evaluating clinical effectiveness of specific aspects of the pharmacy benefit, including but not limited to the specialty drug and home infusion therapy programs.

C.7.9.1. Clinical Services Program

The contractor shall provide clinical services in conjunction with all pharmaceuticals designated on the DoD clinical services drug list and dispensed through the mail order pharmacy, including contractor-owned specialty pharmacies designated as DoD specialty mail order outlets. Final decisions of the Director, TRICARE Management Activity regarding changes to the identification of pharmaceuticals subject to clinical services and change implementation dates are published in the quarterly DoD Pharmacy and Therapeutic Committee Minutes at http://www.tricare.mil/pharmacyiPTCmte/default.htm.

The contractor shall provide clinical support services to beneficiaries receiving designated medications through its mail order or specialty pharmacies. These services shall include, but are not limited to:

A. Optimizing therapeutic outcome by minimizing adverse clinical events, minimizing waste, and achieving a high level of beneficiary satisfaction.

B. Conducting patient centric adherence monitoring and member education programs: optimize medication adherence (education, reminders, side-effect management) for specialty drug products with poor adherence…