TOP_21_SF33_Section_B.pdf

HT940219R0001

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

1 211

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) depository 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

08/01/2019 X

HT9402

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011

until 1200 MT local time 10/31/2019

MATTHEW ANDERSON 303

matthew.l.anderson18.civ@ mail.676-3754

X

X

X

X

X

X

X

X

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X

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PAGE(S)

MARGARET A. ZANCANELLA

AUTHORIZED FOR LOCAL REPRODUCTION

Previous edition is unusable

STANDARD FORM 33 (Rev. 9-97)

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

2-26

C1-C57 D1 E1 F1-F5 G1-G22 H1-H29

I1-I29

J1

K1-K7

L1-L24

M1-M9

See Section L

303-676-3451

Margaret.a.zancanella.civ@mail.mil

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

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CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940219R0001

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

0001 1 LO

0003 1 LO

TRICARE OVERSEAS PROGRAM (TOP) 2021 Indefinite

Delivery/Indefinite Quantity Overseas Health Care

Support Contract in accordance with FAR Clause

52.216-1, Contract Type, for the scheduled period and for Option Periods 1-7 if exercised. All services shall be ordered in accordance with

Sections G and I, FAR Clauses 52.216-19, Order

Limitations; and 52.216-22, Indefinite Quantity;

and DFARS Clause 252.216-7006, Ordering. PSC:

Q201, Medical - General Healthcare; NAICS:

524114, Direct Health and Medical Insurance

Carriers.

Guaranteed Minimum: TBD (Award value of CLIN 0001)

Contract Ceiling: $995,000,000(Award Value, includes all CLINs X014, Transition-Out and

52.217-8 6 Month Extension)

Delivery Location Code: HT9402

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011-9066 USA

SECTION B, SUPPLIES OR SERVICES AND PRICES/COSTS.

Base Period (TRANSITION-IN): 12 months from the date of award.

TRANSITION-IN (Firm Fixed Price)

Planning and implementation of transition-in activities as stated in Section C.26. of the contract.

LO = Lot

DELIVERABLES, DD FORM 1423-1, CONTRACT DATA

REQUIREMENTS LIST (CDRLs) FOR TRANSITION-IN CDRLS

CDRLs(DD1423) as stated in Section C, Section

F.5, and Section J, Exhibit A of the contract.

(Not Separately Priced)

PERFORMANCE READINESS VALIDATION/PERFORMANCE

READINESS ASSESSMENT AND VERIFICATION (Firm Fixed

Price)

Continued ...

NSP

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

Administrative and support cost associated with providing the services as stated in Section

C.26.4 and C.26.5 of the contract.

LO = Lot

Option Period (OP) 1 (12 months)

For any CLIN with Unit of Issue "Each", the quantities are estimated

1001 HEALTH CARE SUPPORT SERVICES - PRIME ENROLLED 3358164 EA

MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

1002 HEALTH CARE SUPPORT SERVICES - PRIME REMOTE 283272 EA

ENROLLED MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

1003 TRANSIENT CARE MANAGEMENT (Fixed Unit Price) 6221 EA

Administrative and support costs associated with providing the services for urgent/emergency care as stated in Section C.21 of the contract.

EA = Each Case

(Option Line Item)

1004 TRANSIENT AMBULANCE/AEROMEDICAL EVACUATION 200 EA

SERVICES (Fixed Unit Price)

Administration and support costs associated with providing transient ambulance/aeromedical evacuation services as stated in Section C.14. of the contract.

Continued ...

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CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

EA = Each Case

(Option Line Item)

1005 WRITTEN TRANSLATION SERVICES - ROUTINE (Fixed 152064 EA

Unit Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

1006 WRITTEN TRANSLATION SERVICES - URGENT (Fixed Unit 16896 EA

Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

1007 CLAIMS PROCESSING FEE - TRICARE ELIGIBLE (DEFENSE 561049 EA

HEALTHCARE PROGRAM (DHP)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

1008 CLAIMS PROCESSING FEE - MEDICARE ELIGIBLE 42311 EA

(MEDICARE ELIGIBLE RETIREE HEALTH CARE FUND

(MERHCF)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

1009 ACCESS TO CARE IN KINSHASA, DEMOCRATIC REPUBLIC 360 EA

OF THE CONGO (Fixed Unit Price)

Continued ...

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

Access to care in Kinshasa, Democratic Republic of the Congo as stated in Section C.42.2. of the contract.

EA = Each Member Per Month.

(Option Line Item)

1010 MEDICAL CAPABILITY REPORTS (Fixed Unit Price). 100 EA

Administrative and support costs associated with providing services as stated in Section C.22. of the contract.

EA = Each Report

(Option Line Item)

1011 BLOCK OVERFLIGHT PERMITS (Firm Fixed Price). 1 LO

Administrative and support costs associated with providing Block Overflight Permits as stated in

Section C.14.10 and C.14.11 of the contract.

LO = Lot

(Option Line Item)

1012 PERFORMANCE INCENTIVE POOL 1 LO

OPTION PERIOD 1 INCENTIVES UP TO $221,974.

See Section H.6. of the contract for criteria for earning incentives. The amount shown is the maximum incentive available for OP1.

LO = Lot

(Option Line Item)

1013 DELIVERABLES, DD FORM 1423-1, CONTRACT DATA

REQUIREMENTS LIST (CDRLs)

CDRLs(DD1423) as stated in Section C, Section

F.5, and Section J, Exhibit A of the contract.

(Option Line Item)

(Not Separately Priced)

1014 TRANSITION-OUT - IF EXERCISED (Firm Fixed Price) 1 LO

Continued ...

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

Implementation of transition-out activities as stated in Section C.26. of the contract.

LO = Lot

(Option Line Item)

Option Period (OP) 2 (12 months)

For any CLIN with Unit of Issue "Each", the quantities are estimated

2001 HEALTH CARE SUPPORT SERVICES - PRIME ENROLLED 3358164 EA

MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

2002 HEALTH CARE SUPPORT SERVICES - PRIME REMOTE 283272 EA

ENROLLED MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

2003 TRANSIENT CARE MANAGEMENT (Fixed Unit Price) 6221 EA

Administrative and support costs associated with providing the services for urgent/emergency care as stated in Section C.21 of the contract.

EA = Each Case

(Option Line Item)

2004 TRANSIENT AMBULANCE/AEROMEDICAL EVACUATION 200 EA

SERVICES (Fixed Unit Price)

Administration and support costs associated with providing transient ambulance/aeromedical evacuation services as stated in Section C.14. of the contract.

Continued ...

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

EA = Each Case

(Option Line Item)

2005 WRITTEN TRANSLATION SERVICES - ROUTINE (Fixed 152064 EA

Unit Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

2006 WRITTEN TRANSLATION SERVICES - URGENT (Fixed Unit 16896 EA

Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

2007 CLAIMS PROCESSING FEE - TRICARE ELIGIBLE (DEFENSE 561049 EA

HEALTHCARE PROGRAM (DHP)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

2008 CLAIMS PROCESSING FEE - MEDICARE ELIGIBLE 42311 EA

(MEDICARE ELIGIBLE RETIREE HEALTH CARE FUND

(MERHCF)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

2009 ACCESS TO CARE IN KINSHASA, DEMOCRATIC REPUBLIC 360 EA

OF THE CONGO (Fixed Unit Price)

Continued ...

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CONTINUATION SHEET

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

Access to care in Kinshasa, Democratic Republic of the Congo as stated in Section C.42.2. of the contract.

EA = Each Member Per Month.

(Option Line Item)

2010 MEDICAL CAPABILITY REPORTS (Fixed Unit Price). 100 EA

Administrative and support costs associated with providing services as stated in Section C.22. of the contract.

EA = Each Report

(Option Line Item)

2011 BLOCK OVERFLIGHT PERMITS (Firm Fixed Price). 1 LO

Administrative and support costs associated with providing Block Overflight Permits as stated in

Section C.14.10 and C.14.11 of the contract.

LO = Lot

(Option Line Item)

2012 PERFORMANCE INCENTIVE POOL 1 LO

OPTION PERIOD 2 INCENTIVES UP TO $226,413.

See Section H.6. of the contract for criteria for earning incentives. The amount shown is the maximum incentive available for OP2.

LO = Lot

(Option Line Item)

2013 DELIVERABLES, DD FORM 1423-1, CONTRACT DATA

REQUIREMENTS LIST (CDRLs)

CDRLs(DD1423) as stated in Section C, Section

F.5, and Section J, Exhibit A of the contract.

(Option Line Item)

(Not Separately Priced)

2014 TRANSITION-OUT - IF EXERCISED (Firm Fixed Price) 1 LO

Continued ...

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REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

Implementation of transition-out activities as stated in Section C.26. of the contract.

LO = Lot

(Option Line Item)

Option Period (OP) 3 (12 months)

For any CLIN with Unit of Issue "Each", the quantities are estimated

3001 HEALTH CARE SUPPORT SERVICES - PRIME ENROLLED 3358164 EA

MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

3002 HEALTH CARE SUPPORT SERVICES - PRIME REMOTE 283272 EA

ENROLLED MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

3003 TRANSIENT CARE MANAGEMENT (Fixed Unit Price) 6221 EA

Administrative and support costs associated with providing the services for urgent/emergency care as stated in Section C.21 of the contract.

EA = Each Case

(Option Line Item)

3004 TRANSIENT AMBULANCE/AEROMEDICAL EVACUATION 200 EA

SERVICES (Fixed Unit Price)

Administration and support costs associated with providing transient ambulance/aeromedical evacuation services as stated in Section C.14. of the contract.

Continued ...

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REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

EA = Each Case

(Option Line Item)

3005 WRITTEN TRANSLATION SERVICES - ROUTINE (Fixed 152064 EA

Unit Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

3006 WRITTEN TRANSLATION SERVICES - URGENT (Fixed Unit 16896 EA

Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

3007 CLAIMS PROCESSING FEE - TRICARE ELIGIBLE (DEFENSE 561049 EA

HEALTHCARE PROGRAM (DHP)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

3008 CLAIMS PROCESSING FEE - MEDICARE ELIGIBLE 42311 EA

(MEDICARE ELIGIBLE RETIREE HEALTH CARE FUND

(MERHCF)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

3009 ACCESS TO CARE IN KINSHASA, DEMOCRATIC REPUBLIC 360 EA

OF THE CONGO (Fixed Unit Price)

Continued ...

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CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

Access to care in Kinshasa, Democratic Republic of the Congo as stated in Section C.42.2. of the contract.

EA = Each Member Per Month.

(Option Line Item)

3010 MEDICAL CAPABILITY REPORTS (Fixed Unit Price). 100 EA

Administrative and support costs associated with providing services as stated in Section C.22. of the contract.

EA = Each Report

(Option Line Item)

3011 BLOCK OVERFLIGHT PERMITS (Firm Fixed Price). 1 LO

Administrative and support costs associated with providing Block Overflight Permits as stated in

Section C.14.10 and C.14.11 of the contract.

LO = Lot

(Option Line Item)

3012 PERFORMANCE INCENTIVE POOL 1 LO

OPTION PERIOD 3 INCENTIVES UP TO $230,942.

See Section H.6. of the contract for criteria for earning incentives. The amount shown is the maximum incentive available for OP3.

LO = Lot

(Option Line Item)

3013 DELIVERABLES, DD FORM 1423-1, CONTRACT DATA

REQUIREMENTS LIST (CDRLs)

CDRLs(DD1423) as stated in Section C, Section

F.5, and Section J, Exhibit A of the contract.

(Option Line Item)

(Not Separately Priced)

3014 TRANSITION-OUT - IF EXERCISED (Firm Fixed Price) 1 LO

Continued ...

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CONTINUATION SHEET

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

Implementation of transition-out activities as stated in Section C.26. of the contract.

LO = Lot

(Option Line Item)

Option Period (OP) 4 (12 months)

For any CLIN with Unit of Issue "Each", the quantities are estimated

4001 HEALTH CARE SUPPORT SERVICES - PRIME ENROLLED 3358164 EA

MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

4002 HEALTH CARE SUPPORT SERVICES - PRIME REMOTE 283272 EA

ENROLLED MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

4003 TRANSIENT CARE MANAGEMENT (Fixed Unit Price) 6221 EA

Administrative and support costs associated with providing the services for urgent/emergency care as stated in Section C.21 of the contract.

EA = Each Case

(Option Line Item)

4004 TRANSIENT AMBULANCE/AEROMEDICAL EVACUATION 200 EA

SERVICES (Fixed Unit Price)

Administration and support costs associated with providing transient ambulance/aeromedical evacuation services as stated in Section C.14. of the contract.

Continued ...

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CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

EA = Each Case

(Option Line Item)

4005 WRITTEN TRANSLATION SERVICES - ROUTINE (Fixed 152064 EA

Unit Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

4006 WRITTEN TRANSLATION SERVICES - URGENT (Fixed Unit 16896 EA

Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

4007 CLAIMS PROCESSING FEE - TRICARE ELIGIBLE (DEFENSE 561049 EA

HEALTHCARE PROGRAM (DHP)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

4008 CLAIMS PROCESSING FEE - MEDICARE ELIGIBLE 42311 EA

(MEDICARE ELIGIBLE RETIREE HEALTH CARE FUND

(MERHCF)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

4009 ACCESS TO CARE IN KINSHASA, DEMOCRATIC REPUBLIC 360 EA

OF THE CONGO (Fixed Unit Price)

Continued ...

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CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

Access to care in Kinshasa, Democratic Republic of the Congo as stated in Section C.42.2. of the contract.

EA = Each Member Per Month.

(Option Line Item)

4010 MEDICAL CAPABILITY REPORTS (Fixed Unit Price). 100 EA

Administrative and support costs associated with providing services as stated in Section C.22. of the contract.

EA = Each Report

(Option Line Item)

4011 BLOCK OVERFLIGHT PERMITS (Firm Fixed Price). 1 LO

Administrative and support costs associated with providing Block Overflight Permits as stated in

Section C.14.10 and C.14.11 of the contract.

LO = Lot

(Option Line Item)

4012 PERFORMANCE INCENTIVE POOL 1 LO

OPTION PERIOD 4 INCENTIVES UP TO $235,560.

See Section H.6. of the contract for criteria for earning incentives. The amount shown is the maximum incentive available for OP4.

LO = Lot

(Option Line Item)

4013 DELIVERABLES, DD FORM 1423-1, CONTRACT DATA

REQUIREMENTS LIST (CDRLs)

CDRLs(DD1423) as stated in Section C, Section

F.5, and Section J, Exhibit A of the contract.

(Option Line Item)

(Not Separately Priced)

4014 TRANSITION-OUT - IF EXERCISED (Firm Fixed Price) 1 LO

Continued ...

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

Implementation of transition-out activities as stated in Section C.26. of the contract.

LO = Lot

(Option Line Item)

Option Period (OP) 5 (12 months)

For any CLIN with Unit of Issue "Each", the quantities are estimated

5001 HEALTH CARE SUPPORT SERVICES - PRIME ENROLLED 3358164 EA

MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

5002 HEALTH CARE SUPPORT SERVICES - PRIME REMOTE 283272 EA

ENROLLED MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

5003 TRANSIENT CARE MANAGEMENT (Fixed Unit Price) 6221 EA

Administrative and support costs associated with providing the services for urgent/emergency care as stated in Section C.21 of the contract.

EA = Each Case

(Option Line Item)

5004 TRANSIENT AMBULANCE/AEROMEDICAL EVACUATION 200 EA

SERVICES (Fixed Unit Price)

Administration and support costs associated with providing transient ambulance/aeromedical evacuation services as stated in Section C.14. of the contract.

Continued ...

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

EA = Each Case

(Option Line Item)

5005 WRITTEN TRANSLATION SERVICES - ROUTINE (Fixed 152064 EA

Unit Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

5006 WRITTEN TRANSLATION SERVICES - URGENT (Fixed Unit 16896 EA

Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

5007 CLAIMS PROCESSING FEE - TRICARE ELIGIBLE (DEFENSE 561049 EA

HEALTHCARE PROGRAM (DHP)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

5008 CLAIMS PROCESSING FEE - MEDICARE ELIGIBLE 42311 EA

(MEDICARE ELIGIBLE RETIREE HEALTH CARE FUND

(MERHCF)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

5009 ACCESS TO CARE IN KINSHASA, DEMOCRATIC REPUBLIC 360 EA

OF THE CONGO (Fixed Unit Price)

Continued ...

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CONTINUATION SHEET

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

Access to care in Kinshasa, Democratic Republic of the Congo as stated in Section C.42.2. of the contract.

EA = Each Member Per Month.

(Option Line Item)

5010 MEDICAL CAPABILITY REPORTS (Fixed Unit Price). 100 EA

Administrative and support costs associated with providing services as stated in Section C.22. of the contract.

EA = Each Report

(Option Line Item)

5011 BLOCK OVERFLIGHT PERMITS (Firm Fixed Price). 1 LO

Administrative and support costs associated with providing Block Overflight Permits as stated in

Section C.14.10 and C.14.11 of the contract.

LO = Lot

(Option Line Item)

5012 PERFORMANCE INCENTIVE POOL 1 LO

OPTION PERIOD 5 INCENTIVES UP TO $240,272.

See Section H.6. of the contract for criteria for earning incentives. The amount shown is the maximum incentive available for OP5.

LO = Lot

(Option Line Item)

5013 DELIVERABLES, DD FORM 1423-1, CONTRACT DATA

REQUIREMENTS LIST (CDRLs)

CDRLs(DD1423) as stated in Section C, Section

F.5, and Section J, Exhibit A of the contract.

(Option Line Item)

(Not Separately Priced)

5014 TRANSITION-OUT - IF EXERCISED (Firm Fixed Price) 1 LO

Continued ...

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REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940219R0001

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

Implementation of transition-out activities as stated in Section C.26. of the contract.

LO = Lot

(Option Line Item)

Option Period (OP) 6 (12 months)

For any CLIN with Unit of Issue "Each", the quantities are estimated

6001 HEALTH CARE SUPPORT SERVICES - PRIME ENROLLED 3358164 EA

MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

6002 HEALTH CARE SUPPORT SERVICES - PRIME REMOTE 283272 EA

ENROLLED MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

6003 TRANSIENT CARE MANAGEMENT (Fixed Unit Price) 6221 EA

Administrative and support costs associated with providing the services for urgent/emergency care as stated in Section C.21 of the contract.

EA = Each Case

(Option Line Item)

6004 TRANSIENT AMBULANCE/AEROMEDICAL EVACUATION 200 EA

SERVICES (Fixed Unit Price)

Administration and support costs associated with providing transient ambulance/aeromedical evacuation services as stated in Section C.14. of the contract.

Continued ...

19 211

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940219R0001

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

EA = Each Case

(Option Line Item)

6005 WRITTEN TRANSLATION SERVICES - ROUTINE (Fixed 152064 EA

Unit Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

6006 WRITTEN TRANSLATION SERVICES - URGENT (Fixed Unit 16896 EA

Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

6007 CLAIMS PROCESSING FEE - TRICARE ELIGIBLE (DEFENSE 561049 EA

HEALTHCARE PROGRAM (DHP)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

6008 CLAIMS PROCESSING FEE - MEDICARE ELIGIBLE 42311 EA

(MEDICARE ELIGIBLE RETIREE HEALTH CARE FUND

(MERHCF)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

6009 ACCESS TO CARE IN KINSHASA, DEMOCRATIC REPUBLIC 360 EA

OF THE CONGO (Fixed Unit Price)

Continued ...

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CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940219R0001

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

Access to care in Kinshasa, Democratic Republic of the Congo as stated in Section C.42.2. of the contract.

EA = Each Member Per Month.

(Option Line Item)

6010 MEDICAL CAPABILITY REPORTS (Fixed Unit Price). 100 EA

Administrative and support costs associated with providing services as stated in Section C.22. of the contract.

EA = Each Report

(Option Line Item)

6011 BLOCK OVERFLIGHT PERMITS (Firm Fixed Price). 1 LO

Administrative and support costs associated with providing Block Overflight Permits as stated in

Section C.14.10 and C.14.11 of the contract.

LO = Lot

(Option Line Item)

6012 PERFORMANCE INCENTIVE POOL 1 LO

OPTION PERIOD 6 INCENTIVES UP TO $246,278.

See Section H.6. of the contract for criteria for earning incentives. The amount shown is the maximum incentive available for OP6.

LO = Lot

(Option Line Item)

6013 DELIVERABLES, DD FORM 1423-1, CONTRACT DATA

REQUIREMENTS LIST (CDRLs)

CDRLs(DD1423) as stated in Section C, Section

F.5, and Section J, Exhibit A of the contract.

(Option Line Item)

(Not Separately Priced)

6014 TRANSITION-OUT - IF EXERCISED (Firm Fixed Price) 1 LO

Continued ...

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CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940219R0001

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

Implementation of transition-out activities as stated in Section C.26. of the contract.

LO = Lot

(Option Line Item)

Option Period (OP) 7 (12 months)

For any CLIN with Unit of Issue "Each", the quantities are estimated

7001 HEALTH CARE SUPPORT SERVICES - PRIME ENROLLED 3358164 EA

MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

7002 HEALTH CARE SUPPORT SERVICES - PRIME REMOTE 283272 EA

ENROLLED MEMBERS (Fixed Unit Price)

Administrative and support costs associated with providing all services as stated in Section

C.1.2. of the contract.

EA = Each Member Per Month X 12 Months

(Option Line Item)

7003 TRANSIENT CARE MANAGEMENT (Fixed Unit Price) 6221 EA

Administrative and support costs associated with providing the services for urgent/emergency care as stated in Section C.21 of the contract.

EA = Each Case

(Option Line Item)

7004 TRANSIENT AMBULANCE/AEROMEDICAL EVACUATION 200 EA

SERVICES (Fixed Unit Price)

Administration and support costs associated with providing transient ambulance/aeromedical evacuation services as stated in Section C.14. of the contract.

Continued ...

22 211

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940219R0001

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

EA = Each Case

(Option Line Item)

7005 WRITTEN TRANSLATION SERVICES - ROUTINE (Fixed 152064 EA

Unit Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

7006 WRITTEN TRANSLATION SERVICES - URGENT (Fixed Unit 16896 EA

Price)

Translation Services as stated in Section C.19.

of the contract.

EA = Each Page

(Option Line Item)

7007 CLAIMS PROCESSING FEE - TRICARE ELIGIBLE (DEFENSE 561049 EA

HEALTHCARE PROGRAM (DHP)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

7008 CLAIMS PROCESSING FEE - MEDICARE ELIGIBLE 42311 EA

(MEDICARE ELIGIBLE RETIREE HEALTH CARE FUND

(MERHCF)) (Fixed Unit Price)

Administrative and support costs associated with providing services as stated in Section C.16. of the contract.

EA = Each Claim

(Option Line Item)

7009 ACCESS TO CARE IN KINSHASA, DEMOCRATIC REPUBLIC 360 EA

OF THE CONGO (Fixed Unit Price)

Continued ...

23 211

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940219R0001

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

Access to care in Kinshasa, Democratic Republic of the Congo as stated in Section C.42.2. of the contract.

EA = Each Member Per Month.

(Option Line Item)

7010 MEDICAL CAPABILITY REPORTS (Fixed Unit Price). 100 EA

Administrative and support costs associated with providing services as stated in Section C.22. of the contract.

EA = Each Report

(Option Line Item)

7011 BLOCK OVERFLIGHT PERMITS (Firm Fixed Price). 1 LO

Administrative and support costs associated with providing Block Overflight Permits as stated in

Section C.14.10 and C.14.11 of the contract.

LO = Lot

(Option Line Item)

7012 PERFORMANCE INCENTIVE POOL 1 LO

OPTION PERIOD 7 INCENTIVES UP TO $252,435.

See Section H.6. of the contract for criteria for earning incentives. The amount shown is the maximum incentive available for OP7.

LO = Lot

(Option Line Item)

7013 DELIVERABLES, DD FORM 1423-1, CONTRACT DATA

REQUIREMENTS LIST (CDRLs)

CDRLs(DD1423) as stated in Section C, Section

F.5, and Section J, Exhibit A of the contract.

(Option Line Item)

(Not Separately Priced)

7014 TRANSITION-OUT - IF EXERCISED (Firm Fixed Price) 1 LO

Continued ...

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CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940219R0001

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

Implementation of transition-out activities as stated in Section C.26. of the contract.

LO = Lot

(Option Line Item)