HT940220R0002 SF33 and Section B 20191202.pdf

FACILITY_CAGE_CO

HT940220R0002

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 3

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

X

HT9402

DEFENSE HEALTH AGENCY

DEFENSE HEALTH AGENCY-AURORA

16401 E CENTRETECH PARKWAY

AURORA CO 80011

1200 MS

Dwight Bonham 303 dwight.d.bonham.civ@mail.

mil676-3731

PAGE(S)

Hilary Meckel

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

HILARY.O.MECKEL.CIV@MAIL.MIL

FAR 52.215-3 Request for Information or Solicitation for Planning Purposes

DRAFT

X

X

X

X

X

X

X

X

X

X

X

X

X

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 3

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0002

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

0001 Contract Transition-In, 1 LO

TRICARE Pharmacy Services

0002 Government Directed Notifications, 9500000 EA

Transition-In

0003 Contract Data Requirements List (CDRL) 1 LO

X001 Retail Network Claims, TBD EA TRICARE Only-Eligible

(Option Line Item)

X002 Retail Network Claims, TBD EA Medicare Dual-Eligible

(Option Line Item)

X003 Specialty Network Claims TBD EA TRICARE Only-Eligible

(Option Line Item)

X004 Specialty Network Claims TBD EA Medicare Dual-Eligible

(Option Line Item)

X005 MTF Prescriptions, Adjudication Services TBD EA (Option Line Item)

X006 Mail Order Pharmacy, Prescription Fill TBD EA TRICARE Only-Eligible

(Option Line Item)

Continued ...

NAME OF OFFEROR OR CONTRACTOR

3 3

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0002

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

X007 Mail Order Pharmacy, Prescription Fill TBD EA Medicare Dual-Eligible

(Option Line Item)

X008 Mail Order Unreplenished Agents 1 LO (Option Line Item)

X009 Market Priced Pharmaceutical Program - MPPP TBD EA Administrative Fee

(Option Line Item)

X010 1 LOMarket Priced Pharmaceutical Program -

MPPP, Savings Offer Drugs (Option Line Item)

X011 1 LOMarket Priced Pharmaceutical Program - MPPP Sustainment Offer Drugs (Option Line Item)

X012 Clinical Reviews (PA & MN) TBD EA TRICARE Only-Eligible

(Option Line Item)

X013 Clinical Reviews (PA & MN) TBD EA Medicare Dual-Eligible

(Option Line Item)

X014 TRICARE Pharmacy Svcs, Administrative Support 114000000 PM (Option Line Item)

X015 Contract Data Requirements List (CDRL) 1 LO (Option Line Item)

Continued ...

NAME OF OFFEROR OR CONTRACTOR

4 3

CONTINUATION SHEET

REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0002

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

X016 Retail Network Cost Control Incentive 1 LO

(Option Line Item)

X017 Specialty Network Cost Control Incentive 1 LO

(Option Line Item)

X018 Market Price Pharmaceutical Program - MPPP 1 LO

(Savings Offers Only) Cost Control Incentive

(Option Line Item)

X019 Award Fee Incentive, OP_ (Option Line Item)

(Not Separately Priced)

X019AA Award Fee, 1st Six Months, OP_ 1 LO

(Option Line Item)

X019AB Award Fee, 2nd Six Months, OP_ 1 LO

(Option Line Item)

X020 Contract Phase-Out, Non-Incumbent 1 LO

(Option Line Item)

X021 Contract Phase-Out, Incumbent 1 LO

(Option Line Item)

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