EXHIBIT_L-12_Instructions_for_Completing_Retail_Network_Reimbursement _Table_L-1_(Aug_13 _2013).pdf

Exhibit L-12 TRICARE Pharmacy Program

HT9402-13-R-0001 L-12

Instructions for Completing Retail Network Reimbursement, Table L-1

Instructions for Completing Table L-1

NOTE: In the event of award, contract Section H, Table H-1 will be completed by the Contracting Officer to reflect the offer at Table L-1.

Offerors are required to complete the following portions of Table L-1:

• Guaranteed Average Price Adjustment Percentage

• Guaranteed Average Dispensing Fee

• Average Drug Cost

• Estimated Total Drug Costs

• Subtotal, Estimated Total Drug Costs, for each Option Period

• Total Expected Government Cost for Reimbursement of Retail Network Costs for Option

Periods 1 through 7

The instructions for completing each of these portions are as follows:

Guaranteed Average Price Adjustment Percentage – This is the percentage adjustment (which may be either a “plus” or “minus”) from the Average Wholesale Acquisition Cost (WAC) that the offeror guarantees. This is to be expressed to two decimal places and should reflect a “plus” or “minus” sign as applicable; i.e., +2.04%; – 5.00%; etc.

If prepared in the MS Word document or other non-spreadsheet application, a positive adjustment to the Average WAC should reflect a “+” sign preceding the percent adjustment and a reduction from the Average WAC should reflect a “–“ sign preceding the percentage adjustment.

Examples follow showing an Average WAC with positive ( + 10.00%) and negative ( – 10.00%) Guaranteed Average Price Adjustments made, using the same Guaranteed Average Dispensing Fee:

Average WAC

Guaranteed Average Price Adjustment

Percentage

Guaranteed Average Dispensing Fee

Average Drug

Cost $124.00 10.00% $2.00 $138.40 $124.00 – 10.00% $2.00 $113.60

A Guaranteed Average Price Adjustment Percentage shall be listed for each category of prescription for each Option Period.

Guaranteed Average Dispensing Fee – This is the offeror’s guaranteed average dispensing fee per prescription filled. This is to be expressed to two decimal places in dollar format; i.e., $1.99, $0.50; etc.

The Guaranteed Average Dispensing Fee shall be listed for each type of prescription, and for each Option Period. For example, if the offeror guarantees a $1.50 dispensing fee for non-specialty brand name drugs in Option Period 1 and $1.75 in each succeeding option period for non-specialty brand name drugs, the table would be populated to reflect “$1.50” in Option Period 1 (for non-specialty brand name drugs) and “$1.75” (for non-specialty brand name drugs) each for Option Periods 2 through 7. For the successful offeror, the government will utilize the “Guaranteed Average Dispensing Fee” figures filled in Table L-1 and populate the Network Reimbursement Table H-1 with the respective figures.

Exhibit L-12 TRICARE Pharmacy Program

HT9402-13-R-0001 L-12

Average Drug Cost – This is the product of multiplying the government-specified Average WAC by one plus the offeror’s Guaranteed Average Price Adjustment Percentage, and then adding the offeror’s Guaranteed Average Dispensing Fee to that product. This result is to be expressed in whole dollars, with no cents. This calculation is to be made for each of the four prescription types. This is expressed mathematically as:

Average Drug Cost = [(Average WAC) x (1 + Guaranteed Average Price Adjustment

Percentage)] + Guaranteed Average Dispensing Fee

Estimated Total Drug Costs – This is the product of multiplying the Average Drug Cost (defined above) by the Estimated Quantity of prescriptions. This result is to be expressed in whole dollars, with no cents. This calculation is to be made for each of the four prescription types.

Subtotals for each Option Period – This is the summation of the “Estimated Total Drug Costs” for each of the four prescription types, for each option period. This result is to be expressed in whole dollars, with no cents. This calculation is to be made for each option period.

Total Expected Government Cost for Reimbursement of Retail Network Pharmacy Costs for Option Periods 1 through 7 -- This is the summation of the “Estimated Total Drug Costs” subtotals for Option Periods 1 through 7. This result is to be expressed in whole dollars, with no cents.