HT940220R0002 TPharm5 Amendment 00005 20201002.pdf

(x) x 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.

HT9402

AURORA CO 80011-9066

16401 E CENTRETECH PARKWAY

DEFENSE HEALTH AGENCY COD-AB

DEPARTMENT OF DEFENSE

HT9402

AURORA CO 80011-9066

16401 E CENTRETECH PARKWAY

DEFENSE HEALTH AGENCY COD-AB

DEPARTMENT OF DEFENSE

13. THIS ITEM ONLY APPLIES TO MODIFICATION OF CONTRACTS/ORDERS. IT MODIFIES THE CONTRACT/ORDER NO. AS DESCRIBED IN ITEM 14.

12. ACCOUNTING AND APPROPRIATION DATA (If required) is not extended.

Items 8 and 15, and returning

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

11. THIS ITEM ONLY APPLIES TO AMENDMENTS OF SOLICITATIONS

FACILITY CODE CODE

10B. DATED (SEE ITEM 13)

10A. MODIFICATION OF CONTRACT/ORDER NO.

9A. AMENDMENT OF SOLICITATION NO.

CODE

8. NAME AND ADDRESS OF CONTRACTOR (No., street, county, State and ZIP Code)

7. ADMINISTERED BY (If other than Item 6)CODE 6. ISSUED BY

PAGE OF PAGES

4. REQUISITION/PURCHASE REQ. NO.3. EFFECTIVE DATE 2. AMENDMENT/MODIFICATION NO.

000005

5. PROJECT NO. (If applicable)

1. CONTRACT ID CODE

AMENDMENT OF SOLICITATION/MODIFICATION OF CONTRACT

J

CHECK ONE A. THIS CHANGE ORDER IS ISSUED PURSUANT TO: (Specify authority) THE CHANGES SET FORTH IN ITEM 14 ARE MADE IN THE CONTRACT

B. THE ABOVE NUMBERED CONTRACT/ORDER IS MODIFIED TO REFLECT THE ADMINISTRATIVE CHANGES (such as changes in paying office, C. THIS SUPPLEMENTAL AGREEMENT IS ENTERED INTO PURSUANT TO AUTHORITY OF:

D. OTHER (Specify type of modification and authority) appropriation date, etc.) SET FORTH IN ITEM 14, PURSUANT TO THE AUTHORITY OF FAR 43.103(b).

E. IMPORTANT: Contractor is not, is required to sign this document and return __________________ copies to the issuing office.

ORDER NO. IN ITEM 10A.

Continued ...

15A. NAME AND TITLE OF SIGNER (Type or print)

15C. DATE SIGNED 16B. UNITED STATES OF AMERICA 15B. CONTRACTOR/OFFEROR 16C. DATE SIGNED

(Signature of person authorized to sign) (Signature of Contracting Officer)

STANDARD FORM 30 (REV. 10-83)

Prescribed by GSA

FAR (48 CFR) 53.243

NSN 7540-01-152-8070

Previous edition unusable

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.

16A. NAME AND TITLE OF CONTRACTING OFFICER (Type or print) Hilary Meckel

HILARY.O.MECKEL.CIV@MAIL.MIL

303-676-3812

HT940220R0002

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers is extended, 9B. DATED (SEE ITEM 11)

07/13/2020

10/02/2020

Amendment 5 to HT940220R0002 includes revisions made to Section B - SUPPLIES OR SERVICES AND PRICES/COSTS, Section C - STATEMENT OF WORK, Section G - CONTRACT ADMINISTRATION, Section H - SPECIAL CONTRACT REQUIREMENTS, Section L - INSTRUCTIONS, CONDITIONS & NOTICES TO OFFERORS and Section M - EVALUATION FACTORS FOR AWARD.

Amendment 5 also extends the proposal due date to 1200 Hrs MD, 10/23/2020

10/02/2020

X

HT940220R0002 2 of 4 Ammendment 5

1. Changes to SF-33, Block 9. The due date for proposals is changed to 1200 MD on 10/23/2020.

2. Changes to Section B.

a. CLIN X010, Market Priced Pharmaceutical Program - MPPP, Savings Offer Drugs will not be used in this solicitation. The X010 CLINs have been stuck through on the accompanying Schedule B.

The Government defers any action on deleting this CLIN, or potentially renumbering the CLIN structure of this solicitation until award.

b. Monetary decimal places (.00) indicating whole dollars have been removed from the Unit Prices and Extended Amounts of all CLINs for which offerors will proposed prices.

3. Changes to Section C.

a. C.4.7.6 is revised as follows:

FROM: The Contractor may offer cost saving or sustainment opportunities per C.6.8.22.

Opportunities shall be accounted for in CDRL R140.

TO: The Contractor may identify opportunities for the Market Price Pharmaceutical Program per C.6.8.22. Opportunities shall be accounted for in CDRL R140.

b. C.6.8.22.1 [First two sentences] is revised:

FROM: The Contractor may recommend to the Government the use of Trade Agreement Act (TAA) compliant agent(s) to dispense at TMOP or specialty pharmacy(ies) for agents where supply sources are not stable or are unavailable through the NPV(s) or when the commercial market price provides a substantial cost savings compared to the same pharmaceutical agent(s) available for replenishment.

TO: The Contractor may recommend to the Government sustainment offers of Trade Agreement Act (TAA) compliant agent(s) to dispense at TMOP or specialty pharmacy(ies) where supply sources are not stable or are unavailable through the NPV(s). Such offers may address situations when the only alternative agents available from the NPV(s) are branded agents, or agents otherwise treated as brand, which are more costly to the Government compared to generic agents available in the commercial market.

c. C.6.8.22.3 [6th Bullet] is revised:

FROM: • The proposed total cost to include drug, administrative fee, and estimated incentive (savings offers only).

TO: • The proposed total cost to include drug, administrative fee, and estimated incentive.

4. Changes to Section G.

a. G.3.4.2.7 is revised:

HT940220R0002 3 of 4 Ammendment 5

FROM: CLINs X010 and X011 – Market Price Pharmaceutical Program (MPPP). The total value of pharmaceutical agents for accepted MPPP sustainment offers (allocated by TRICARE-Only Eligible and Dual-Eligible fund type based on utilization) will be paid against CLINs X010 and X011 by the monthly submission of a payment request and only upon the obligation of sufficient funds for MPPP purchases once the entire quantity has been fully dispensed.

TO: CLIN X011 – Market Price Pharmaceutical Program (MPPP). The total value of pharmaceutical agents for accepted MPPP sustainment offers (allocated by TRICARE-Only Eligible and Dual-Eligible fund type based on utilization) will be paid against CLINs X011 by the monthly submission of a payment request and only upon the obligation of sufficient funds for MPPP purchases once the entire quantity has been fully dispensed.

b. G.3.4.2.11 is revised:

FROM: CLINs X018 - Market Price Pharmaceutical Program (MPPP) (Savings Offers Only) - Cost Control Incentive. Any performance incentive earned by the Contractor for savings on generic drugs (savings offers only) (H.3.4.) will be paid against CLINs X018. The Contractor may submit its payment request upon receipt of the contract modification implementing the incentive assessment.

TO: CLIN X018 - Market Price Pharmaceutical Program (MPPP) - Cost Control Incentive.

Any performance incentive earned by the Contractor for savings on generic drugs (H.3.4.) will be paid against CLIN X018. The Contractor may submit its payment request upon receipt of the contract modification implementing the incentive assessment.

5. Changes to Section H.3.4.4. This paragraph is revised

FROM Incentive Amount. The Contractor shall earn a performance incentive for demonstrated savings to the Government equaling 10% of the cost savings for each of the Contractor’s MPPP recommendations implemented at TRICARE Mail Order Pharmacy (TMOP) (this incentive applies only to savings offers, CLIN X028).

TO Incentive Amount. The Contractor shall earn a performance incentive for demonstrated savings to the Government equaling 10% of the cost savings for each of the Contractor’s MPPP recommendations implemented at TRICARE Mail Order Pharmacy (TMOP). Any incentive earned will be reflected in CLIN X018.

6. Section L

a. L.8.1 TAB A – CLIN Schedule is revised:

FROM: The priced Section B, constitutes the price proposal and offer to the Government. Market Price Pharmaceutical Program CLINs (X010 & X011) and Incentive CLINs (X016-X019) are included for contract administration purposes only, therefore offerors shall not propose prices for these CLINs.

TO: The priced Section B, constitutes the price proposal and offer to the Government. The Market Price Pharmaceutical Program CLIN (X011) and Incentive CLINs (X016-X019) are included for contract administration purposes only, therefore offerors shall not propose prices for these CLINs.

HT940220R0002 4 of 4 Ammendment 5

b. L8.1.9 Market Priced Pharmaceutical Program (MPPP) Administrative Fee (CLINs X009) is revised:

FROM: Offerors shall propose a fixed price per unit in dollars and cents (no fractions of cents) by option period representing the cost of developing offers for sustainment or savings accepted by the Government.

TO: Offerors shall propose a fixed price per unit in dollars and cents (no fractions of cents) by option period representing the cost of developing sustainment offers accepted by the Government.

c. L.8.1.10 is revised from:

FROM: Market Priced Pharmaceutical Program (MPPP), Savings (CLINs X010). Offerors will not propose a price for CLIN X010 since this amount represents the estimated aggregate price of Contractor provided pharmaceuticals dispensed as a result of accepted savings offers.

TO: Reserved.

d. L.9. Section L Attachments have been revised as follows:

(1) Attachment L.25, Total Evaluated Cost Spreadsheet (Rev 5) is revised to be consistent with the Government’s decision not to use X010 in this solicitation

7. Changes to Section M.7.1. Total Evaluated Price is revised as follows:

FROM: The total evaluated price will consist of the sum of extended amounts for all Contract Line Items Numbers (CLINs) in Section B except for the Market Price Pharmaceutical Program CLINs (X020 & X021), Incentive CLINs and Award Fee CLINs, plus the total expected Government cost for reimbursement of retail network pharmacy costs, and specialty network pharmacy costs from the tables in Attachments L-2 and L-3.

TO: The total evaluated price will consist of the sum of extended amounts for all Contract Line Items Numbers (CLINs) in Section B except for the Market Price Pharmaceutical Program CLIN (X011), Incentive CLINs and Award Fee CLINs, plus the total expected Government cost for reimbursement of retail network pharmacy costs, and specialty network pharmacy costs from the tables in Attachments L-2 and L-3.

8. A conformed copy of the solicitation is attached. Changes incorporated by Amendment 5 are identified by a vertical bar in the left margin.

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

1 260

C. E-MAIL ADDRESS

EXT.NUMBERAREA CODE

B. TELEPHONE (NO COLLECT CALLS)A. NAME10. 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 MD

Dwight Bonham 303 dha.buckley.acquis-procure.mbx.tpharm5@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

X

X

X

X

X

X

X

X

X

X

X

X

X

C9

07/13/2020

10/23/2020 the Number Of Copies Listed In L.3.2, Table L-1

Mail Room, Defense Health Agency - Aurora 16401 E. Centretech Pkwy, Aurora , CO 80011

Amendment 5

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 260

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, 250000 EA Transition-In

0003 Contract Data Requirements List (CDRL) 1 LO

1001 Retail Network Claims, 22833000 EA TRICARE Only Eligible (Option Line Item)

1002 Retail Network Claims, 26701000 EA Medicare Dual-Eligible (Option Line Item)

1003 Specialty Network Claims 332332 EA TRICARE Only Eligible (Option Line Item)

1004 Specialty Network Claims 493807 EA Medicare Dual-Eligible (Option Line Item)

1005 MTF Prescriptions, Adjudication Services 56428500 EA (Option Line Item)

1006 Mail Order Pharmacy, Prescription Fill 4616500 EA TRICARE Only Eligible (Option Line Item)

Continued ...

NAME OF OFFEROR OR CONTRACTOR

3 260

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0002

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

1007 Mail Order Pharmacy, Prescription Fill 19418000 EA Medicare Dual-Eligible (Option Line Item)

1008 Mail Order Unreplenished Agents 1 LO (Option Line Item)

1009 Market Priced Pharmaceutical Program - MPPP 240 EA Administrative Fee (Option Line Item)

1010 Market Priced Pharmaceutical Program - MPPP, 1 LO Savings Offer Drugs (Option Line Item)

1011 Market Priced Pharmaceutical Program - MPPP 1 LO Sustainment Offer Drugs (Option Line Item)

1012 Clinical Reviews (PA & MN) 276800 EA TRICARE Only Eligible (Option Line Item)

1013 Clinical Reviews (PA & MN) 322700 EA Medicare Dual-Eligible (Option Line Item)

1014 TRICARE Pharmacy Svcs, Administrative Support 43200000 EA (Option Line Item)

1015 Contract Data Requirements List (CDRL) 1 LO (Option Line Item)

Continued ...

NAME OF OFFEROR OR CONTRACTOR

4 260

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0002

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

1016 Retail Network Cost Control Incentive 1 LO (Option Line Item)

1017 Specialty Network Cost Control Incentive 1 LO (Option Line Item)

1018 1 LO

1019AA 1 LO

1019AB 1 LO

1020 1 LO

1021 1 LO

2001 22831500 EA

Market Price Pharmaceutical Program - MPPP Cost Control Incentive (Option Line Item)

Award Fee Incentive, OP1 (Option Line Item) (Not Separately Priced)

Award Fee, 1st Six Months, OP1 $5,000,000 is the Max Award Fee Amount (Option Line Item)

Award Fee, 2nd Six Months, OP1 $5,000,000 is the Max Award Fee Amount (Option Line Item)

Contract Transition-Out, Non-Incumbent (Option Line Item)

Contract Transition-Out, Incumbent (Option Line Item)

Retail Network Claims, TRICARE Only Eligible (Option Line Item)

Continued ...

$2,500,000.00 $2,500,000.00

$3,000,000.00 $3,000,000.00

$3,000,000.00 $3,000,000.00

$2,500,000.00 $2,500,000.00

NAME OF OFFEROR OR CONTRACTOR

5 260

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0002

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

2002 Retail Network Claims, 27360000 EA Medicare Dual-Eligible (Option Line Item)

2003 Specialty Network Claims 360375 EA TRICARE Only Eligible (Option Line Item)

2004 Specialty Network Claims 535508 EA Medicare Dual-Eligible (Option Line Item)

2005 MTF Prescriptions, Adjudication Services 56428500 EA (Option Line Item)

2006 Mail Order Pharmacy, Prescription Fill 4628000 EA TRICARE Only Eligible (Option Line Item)

2007 Mail Order Pharmacy, Prescription Fill 19799000 EA Medicare Dual-Eligible (Option Line Item)

2008 Mail Order Unreplenished Agents 1 LO (Option Line Item)

2009 Market Priced Pharmaceutical Program - MPPP 240 EA Administrative Fee (Option Line Item)

2010 Market Priced Pharmaceutical Program - MPPP, 1 LO Savings Offer Drugs (Option Line Item)

Continued ...

NAME OF OFFEROR OR CONTRACTOR

6 260

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0002

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

2011 Market Priced Pharmaceutical Program - MPPP 1 LO Sustainment Offer Drugs (Option Line Item)

2012 Clinical Reviews (PA & MN) 304500 EA TRICARE Only Eligible (Option Line Item)

2013 Clinical Reviews (PA & MN) 355000 EA Medicare Dual-Eligible (Option Line Item)

2014 TRICARE Pharmacy Svcs, Administrative Support 43380000 EA (Option Line Item)

2015 Contract Data Requirements List (CDRL) 1 LO (Option Line Item)

2016 Retail Network Cost Control Incentive 1 LO (Option Line Item)

2017 Specialty Network Cost Control Incentive 1 LO (Option Line Item)

2018 1 LO

Market Price Pharmaceutical Program - MPPP Cost Control Incentive (Option Line Item)

Award Fee Incentive, OP2 (Option Line Item) (Not Separately Priced)

Continued ...

NAME OF OFFEROR OR CONTRACTOR

7 260

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0002

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

2019AA 1 LOAward Fee, 1st Six Months, OP2 $5.000,000 is the Max Award Fee Amount (Option Line Item)

2019AB 1 LOAward Fee, 2nd Six Months, OP2 $5,000,000 is the Max Award Fee Amount (Option Line Item)

2020 Contract Transition-Out, Non-Incumbent 1 LO (Option Line Item)

2021 Contract Transition-Out, Incumbent 1 LO (Option Line Item)

3001 Retail Network Claims, 22850500 EA TRICARE Only Eligible (Option Line Item)

3002 Retail Network Claims, 28035000 EA Medicare Dual-Eligible (Option Line Item)

3003 Specialty Network Claims 392362 EA TRICARE Only Eligible (Option Line Item)

3004 Specialty Network Claims 583077 EA Medicare Dual-Eligible (Option Line Item)

3005 MTF Prescriptions, Adjudication Services 56428500 EA (Option Line Item)

Continued ...

$3,000,000.00 $3,000,000.00

$3,000,000.00 $3,000,000.00

NAME OF OFFEROR OR CONTRACTOR

8 260

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0002

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

3006 Mail Order Pharmacy, Prescription Fill 4699000 EA TRICARE Only Eligible (Option Line Item)

3007 Mail Order Pharmacy, Prescription Fill 20406000 EA Medicare Dual-Eligible (Option Line Item)

3008 Mail Order Unreplenished Agents 1 LO (Option Line Item)

3009 Market Priced Pharmaceutical Program - MPPP 240 EA Administrative Fee (Option Line Item)

3010 Market Priced Pharmaceutical Program - MPPP, 1 LO Savings Offer Drugs (Option Line Item)

3011 Market Priced Pharmaceutical Program - MPPP 1 LO Sustainment Offer Drugs (Option Line Item)

3012 Clinical Reviews (PA & MN) 335000 EA TRICARE Only Eligible (Option Line Item)

3013 Clinical Reviews (PA & MN) 390500 EA Medicare Dual-Eligible (Option Line Item)

3014 TRICARE Pharmacy Svcs, Administrative Support 43608000 EA Continued ...

NAME OF OFFEROR OR CONTRACTOR

9 260

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0002

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

(Option Line Item)

3015 Contract Data Requirements List (CDRL) 1 LO (Option Line Item)

3016 Retail Network Cost Control Incentive 1 LO (Option Line Item)

3017 Specialty Network Cost Control Incentive 1 LO (Option Line Item)

3018 1 LO

3019AA 1 LO

3019AB 1 LO

3020 1 LO

3021 1 LO

Market Price Pharmaceutical Program - MPPP Cost Control Incentive (Option Line Item)

Award Fee Incentive, OP3 (Option Line Item) (Not Separately Priced)

Award Fee, 1st Six Months, OP3 $5,000,000 is the Max Award Fee Amount (Option Line Item)

Award Fee, 2nd Six Months, OP3 $5,000,000 is the Max Award Fee Amount (Option Line Item)

Contract Transition-Out, Non-Incumbent (Option Line Item)

Contract Transition-Out, Incumbent (Option Line Item)

Continued ...

$2,500,000.00 $2,500,000.00

$2,500,000.00 $2,500,000.00

$3,000,000.00 $3,000,000.00

$3,000,000.00 $3,000,000.00

NAME OF OFFEROR OR CONTRACTOR

10 260

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

HT940220R0002

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

4001 Retail Network Claims, 22890000 EA TRICARE Only Eligible (Option Line Item)

4002 Retail Network Claims, 28723000 EA Medicare Dual-Eligible (Option Line Item)

4003 Specialty Network Claims 428561 EA TRICARE Only Eligible (Option Line Item)

4004 Specialty Network Claims 636910 EA Medicare Dual-Eligible (Option Line Item)

4005 MTF Prescriptions, Adjudication Services 56428500 EA (Option Line Item)

4006 Mail Order Pharmacy, Prescription Fill 4826000 EA TRICARE Only Eligible (Option Line Item)

4007 Mail Order Pharmacy, Prescription Fill 21234000 EA Medicare Dual-Eligible (Option Line Item)

4008 Mail Order Unreplenished Agents 1 LO (Option Line Item)

4009 Market Priced Pharmaceutical Program - MPPP 240 EA Administrative Fee Continued ...

NAME OF OFFEROR OR CONTRACTOR

11 260

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

(Option Line Item)

4010 Market Priced Pharmaceutical Program - MPPP, 1 LO Savings Offer Drugs (Option Line Item)

4011 Market Priced Pharmaceutical Program - MPPP 1 LO Sustainment Offer Drugs (Option Line Item)

4012 Clinical Reviews (PA & MN) 368500 EA TRICARE Only Eligible (Option Line Item)

4013 Clinical Reviews (PA & MN) 429500 EA Medicare Dual-Eligible (Option Line Item)

4014 TRICARE Pharmacy Svcs, Administrative Support 43836000 EA (Option Line Item)

4015 Contract Data Requirements List (CDRL) 1 LO (Option Line Item)

4016 Retail Network Cost Control Incentive 1 LO (Option Line Item)

4017 Specialty Network Cost Control Incentive 1 LO (Option Line Item)

4018 1 LOMarket Price Pharmaceutical Program - MPPP Cost Control Incentive Continued ...

NAME OF OFFEROR OR CONTRACTOR

12 260

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

4019AA 1 LO

4019AB 1 LO

4020 1 LO

4021 1 LO

5001 22950500 EA

(Option Line Item)

Award Fee Incentive, OP4 (Option Line Item) (Not Separately Priced)

Award Fee, 1st Six Months, OP4 $5,000,000 is the Max Award Fee Amount (Option Line Item)

Award Fee, 2nd Six Months, OP4 $5,000,000 is the Max Award Fee Amount (Option Line Item)

Contract Transition-Out, Non-Incumbent (Option Line Item)

Contract Transition-Out, Incumbent (Option Line Item)

Retail Network Claims, TRICARE Only Eligible (Option Line Item)

5002 Retail Network Claims, 29427000 EA Medicare Dual-Eligible (Option Line Item)

5003 Specialty Network Claims 469211 EA TRICARE Only Eligible (Option Line Item)

5004 Specialty Network Claims 697267 EA Continued ...

$3,000,000.00 $3,000,000.00

$3,000,000.00 $3,000,000.00

NAME OF OFFEROR OR CONTRACTOR

13 260

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

Medicare Dual-Eligible (Option Line Item)

5005 MTF Prescriptions, Adjudication Services 56428500 EA (Option Line Item)

5006 Mail Order Pharmacy, Prescription Fill 5006000 EA TRICARE Only Eligible (Option Line Item)

5007 Mail Order Pharmacy, Prescription Fill 22280000 EA Medicare Dual-Eligible (Option Line Item)

5008 Mail Order Unreplenished Agents 1 LO (Option Line Item)

5009 Market Priced Pharmaceutical Program - MPPP 240 EA Administrative Fee (Option Line Item)

5010 Market Priced Pharmaceutical Program - MPPP, 1 LO Savings Offer Drugs (Option Line Item)

5011 Market Priced Pharmaceutical Program - MPPP 1 LO Sustainment Offer Drugs (Option Line Item)

5012 Clinical Reviews (PA & MN) 405300 EA TRICARE Only Eligible (Option Line Item)

Continued ...

NAME OF OFFEROR OR CONTRACTOR

14 260

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

5013 Clinical Reviews (PA & MN) 472500 EA Medicare Dual-Eligible (Option Line Item)

5014 TRICARE Pharmacy Svcs, Administrative Support 43944000 EA (Option Line Item)

5015 Contract Data Requirements List (CDRL) 1 LO (Option Line Item)

5016 Retail Network Cost Control Incentive 1 LO (Option Line Item)

5017 Specialty Network Cost Control Incentive 1 LO (Option Line Item)

5018 1 LO

5019AA 1 LO

5019AB 1 LO

Market Price Pharmaceutical Program - MPPP Cost Control Incentive (Option Line Item)

Award Fee Incentive, OP5 (Option Line Item) (Not Separately Priced)

Award Fee, 1st Six Months, OP5 $5,000,000 is the Max Award Fee Amount (Option Line Item)

Award Fee, 2nd Six Months, OP5 $5,000,000 is the Max Award Fee Amount (Option Line Item)

Continued ...

$2,500,000.00 $2,500,000.00

$2,500,000.00 $2,500,000.00

$3,000,000.00 $3,000,000.00

NAME OF OFFEROR OR CONTRACTOR

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

5020 Contract Transition-Out, Non-Incumbent 1 LO (Option Line Item)

5021 Contract Transition-Out, Incumbent 1 LO (Option Line Item)

6001 Retail Network Claims, 23032000 EA TRICARE Only Eligible (Option Line Item)

6002 Retail Network Claims, 30146500 EA Medicare Dual-Eligible (Option Line Item)

6003 Specialty Network Claims 514469 EA TRICARE Only Eligible (Option Line Item)

6004 Specialty Network Claims 764690 EA Medicare Dual-Eligible (Option Line Item)

6005 MTF Prescriptions, Adjudication Services 56428500 EA (Option Line Item)

6006 Mail Order Pharmacy, Prescription Fill 5237500 EA TRICARE Only Eligible (Option Line Item)

6007 Mail Order Pharmacy, Prescription Fill 23539000 EA Medicare Dual-Eligible (Option Line Item)

Continued ...

NAME OF OFFEROR OR CONTRACTOR

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

6008 Mail Order Unreplenished Agents 1 LO (Option Line Item)

6009 Market Priced Pharmaceutical Program - MPPP 240 EA Administrative Fee (Option Line Item)

6010 Market Priced Pharmaceutical Program - MPPP, 1 LO Savings Offer Drugs (Option Line Item)

6011 Market Priced Pharmaceutical Program - MPPP 1 LO Sustainment Offer Drugs (Option Line Item)

6012 Clinical Reviews (PA & MN) 445900 EA TRICARE Only Eligible (Option Line Item)

6013 Clinical Reviews (PA & MN) 519700 EA Medicare Dual-Eligible (Option Line Item)

6014 TRICARE Pharmacy Svcs, Administrative Support 44052000 EA (Option Line Item)

6015 Contract Data Requirements List (CDRL) 1 LO (Option Line Item)

6016 Retail Network Cost Control Incentive 1 LO (Option Line Item)

Continued ...

NAME OF OFFEROR OR CONTRACTOR

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

6017 Specialty Network Cost Control Incentive 1 LO (Option Line Item)

6018 1 LO

6019AA 1 LO

6019AB 1 LO

6020 1 LO

6021 1 LO

7001 22830500 EA

Market Price Pharmaceutical Program - MPPP Cost Control Incentive (Option Line Item)

Award Fee Incentive, OP6 (Option Line Item) (Not Separately Priced)

Award Fee, 1st Six Months, OP6 $5,000,000 is the Max Award Fee Amount (Option Line Item)

Award Fee, 2nd Six Months, OP6 $5,000,000 is the Max Award Fee Amount (Option Line Item)

Contract Transition-Out, Non-Incumbent (Option Line Item)

Contract Transition-Out, Incumbent (Option Line Item)

Retail Network Claims, TRICARE Only Eligible (Option Line Item)

7002 Retail Network Claims, 30416000 EA Medicare Dual-Eligible (Option Line Item)

Continued ...

$2,500,000.00 $2,500,000.00

$3,000,000.00 $3,000,000.00

$3,000,000.00 $3,000,000.00

NAME OF OFFEROR OR CONTRACTOR

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

7003 Specialty Network Claims 564706 EA TRICARE Only Eligible (Option Line Item)

7004 Specialty Network Claims 839428 EA Medicare Dual-Eligible (Option Line Item)

7005 MTF Prescriptions, Adjudication Services 56428500 EA (Option Line Item)

7006 Mail Order Pharmacy, Prescription Fill 5458000 EA TRICARE Only Eligible (Option Line Item)

7007 Mail Order Pharmacy, Prescription Fill 24788500 EA Medicare Dual-Eligible (Option Line Item)

7008 Mail Order Unreplenished Agents 1 LO (Option Line Item)

7009 Market Priced Pharmaceutical Program - MPPP 240 EA Administrative Fee (Option Line Item)

7010 Market Priced Pharmaceutical Program - MPPP, 1 LO

Savings Offer Drugs (Option Line Item)

7011 Market Priced Pharmaceutical Program - MPPP 1 LO

Sustainment Offer Drugs (Option Line Item) Continued ...

NAME OF OFFEROR OR CONTRACTOR

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

7012 Clinical Reviews (PA & MN) 490400 EA TRICARE Only Eligible (Option Line Item)

7013 Clinical Reviews (PA & MN) 571700 EA Medicare Dual-Eligible (Option Line Item)

7014 TRICARE Pharmacy Svcs, Administrative Support 44064000 EA (Option Line Item)

7015 Contract Data Requirements List (CDRL) 1 LO (Option Line Item)

7016 Retail Network Cost Control Incentive 1 LO (Option Line Item)

7017 Specialty Network Cost Control Incentive 1 LO (Option Line Item)

7018 1 LO

7019AA 1 LO

Market Price Pharmaceutical Program - MPPP Cost Control Incentive (Option Line Item)

Award Fee Incentive, OP7 (Option Line Item) (Not Separately Priced)

Award Fee, 1st Six Months, OP7 $5,000,000 is the Max Award Fee Amount (Option Line Item)

Continued ...

$2,500,000.00 $2,500,000.00

NAME OF OFFEROR OR CONTRACTOR

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

7019AB 1 LOAward Fee, 2nd Six Months, OP7 $5,000,000 is the Max Award Fee Amount (Option Line Item)

7020 Contract Transition-Out, Non-Incumbent 1 LO (Option Line Item)

7021 Contract Transition-Out, Incumbent 1 LO (Option Line Item)

$3,000,000.00 $3,000,000.00

SECTION C

STATEMENT OF WORK

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C.1. Program Description

TRICARE is the Department of Defense (DoD) health care program administered by the Defense Health Agency (DHA) by means of the Military Health System (MHS) for approximately 9.5 million active duty and retired members of the Uniformed Services, and their spouses and children, including TRICARE for Life beneficiaries. The TRICARE Pharmacy Program is authorized under 10 U.S.C. §1074g and 32 C.F.R. 199.21.

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, clinics, and pharmacies) in the United States and overseas. The direct care system cannot support the total demand for health care services and is focused on maintaining the clinical skills of military staff to support medical readiness.

TRICARE 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 MTFs, retail network pharmacies, retail non-network pharmacies, or delivery through the TRICARE 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.

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, which establishes the basic program benefits. Prescriptions for selected pharmaceutical agents may be subject to prior authorization (PA) or utilization review requirements to assure Medical Necessity (MN), 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 (POS) from which the agent is acquired. The mail order and retail portions of this benefit are open to all eligible TRICARE beneficiaries.

Pharmacy benefits management functions under this contract include the following: perform claims adjudication, administer a retail pharmacy network, operate TMOP, process reimbursements for claims filled at retail network and non-network pharmacies, perform clinical reviews, and provide beneficiary and pharmacy support services. The Contractor shall transmit all claim information to the Government’s designated Pharmacy Data Warehouse (PDW).

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C.1.1. Overall Program Objectives

The following objectives identify the desired outcomes of this contract and are supported by the technical requirements in Section C:

• Maximize patient safety through the utilization of best practices.

• Apply the prescription drug benefit consistently and comprehensively in an effective, efficient, and accurate manner.

• Execute a fiscally responsible pharmacy program.

• Establish and maintain a high level of customer and beneficiary satisfaction.

• Provide flexible, effective and collaborative management and quality control for all services and functions.

C.1.2. Definitions

Definitions specific to this contract, or not otherwise in Appendix A of the TRICARE Operations Manual, are provided in J-1.

C.1.3. Government Furnished Information

The Contractor shall interface with the Defense Enrollment Eligibility Reporting System (DEERS), according to the requirements established in the TRICARE Systems Manual.

The Government will provide licenses for the Contractor to access and use DEERS applications.

The Government will provide the Contractor with access to a medical pricing catalog which will be used for replenishment, both at TMOP and designated specialty pharmacies, and for adjudicating MTF Composite Healthcare System (CHCS) claims.

The Government will provide initial Interface Control Documents (ICDs) and some additional technical specifications for the following systems:

• PDW

• CHCS

• Forensic Toxicology Drug Testing Laboratory Information Management System

(FTDTL IMS)

• Immunization Tracking System

• Theater Medical Data Store (TMDS)

• Clinical Data Repository/Health Data Repository (CHDR)

• MHS GENESIS

The Government will provide a quarterly data file for beneficiary mailings related to formulary changes, described under C.9.3.3.

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The Government will provide a semi-annual file of beneficiary addresses for evaluating and reporting on compliance with network access standards.

The DHA Communications will design, develop, and print 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.

The Government will provide the PDW Data Dictionary and Data Schema, as described under C.11.8.

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 (PA) and MN determinations for the past two year period. The Government (via the outgoing contractor) will also provide an Other Health Insurance (OHI) data file.

C.1.4. Requirements Documents

Statutory and Regulatory Authority

• 10 U.S.C. §1074g Pharmacy Benefits Program

• 32 C.F.R. 199 Civilian Health and Medical Program of the Uniform Services

(CHAMPUS)

• 10 U.S.C. §1086 Contracts for Health Benefits for Certain Members, Former Members, and Their Dependents

• 38 U.S.C. §8126 Limitation on Prices of Drugs Procured by Department and Certain other Federal Agencies

When changes are made to the above statutes or regulations, they are automatically incorporated into the contract requirements.

TRICARE Manuals.

C.1.4.2.1. The Contractor shall utilize the current version of the TRICARE Manuals T-2017, published at Attachment J-3, line 11. The manuals are applicable in their entirety.

C.1.4.2.2. The Contractor shall routinely review proposed, pending, and published manual changes and discuss concerns with the Contracting Officer Representative (COR).

C.1.4.2.3. When a new manual change is pending publication (identified with a change number and date), the COR and Contractor shall coordinate to confirm the applicability of a change to the contract.

To the extent practicable, for those manual changes that apply to the contract, the Government and Contractor will negotiate in good faith a bilateral agreement incorporating the change into the contract. This in no way precludes the Government’s exercise of its rights to execute unilateral change orders as circumstances may require.

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Those manual changes that do not apply to the contract will be incorporated into the contract as part of the next modification to incorporate an applicable change (i.e. Manual Changes 1-4 that do not apply will be incorporated at the same time as Manual Change 5, which does apply).

C.1.4.2.4. 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.

In the event of a conflict between language found within the TRICARE Manuals and the contract, the contract prevails.

C.2. General Claims Processing.

C.2.1. The Contractor shall accept and process claims submitted by retail network pharmacies, TMOP, MTF pharmacies, Veteran Affairs (VA) pharmacies, Indian Health Services (IHS) pharmacies, by beneficiaries for direct reimbursement (including non-network), to include batch files submitted from the Department of Veterans Affairs (DVA) and State Medicaid Agencies.

C.2.2. Unless stated otherwise, the Contractor shall include claims adjudication processes outlined in C.2, consisting of eligibility check, application of the correct copayment, identification of OHI, benefit design edits, Drug Utilization Review (DUR) and application of catastrophic cap and deductible updates.

C.2.3. The Contractor shall maintain a complete patient profile, inclusive of all claims processed within the scope of this contract.

C.2.4. Appeal Rights. The Contractor shall not accept appeals from Active Duty Service Members (ADSMs). ADSM are not authorized as appealing parties for TRICARE cost-sharing determinations. ADSM should be directed to their local MTF for review of access to care issues.

C.2.5. If the Contractor receives a prescription or supporting documentation (e.g., paper claim, PA request) for a beneficiary with Contractor-administered OHI, the Contractor shall internally transfer to its commercial operation in lieu of rejecting or returning to source.

C.2.6. Claims Processing System

The Contractor shall provide 24 hours a day, 7 days a week claims processing for all locations, including overseas MTFs.

The Contractor’s claims processing system shall be available no less than 99.5% of the time, excluding external downtime (e.g., DEERS, B2B Gateway, etc.). The system is considered to be unavailable when the failure rate for claims exceeds 25% for at least 30 minutes.

C.2.6.2.1. The Contractor shall provide reporting on system processing performance per Contract Data Requirements List (CDRL) M060. At the request of the Government, the

HT940220R0002 Page C5 of C78 Amendment 5

Contractor shall provide documentation of reported downtime, including detailed explanation of the causes.

C.2.6.2.2. Contractor downtime concurrent with external system downtime is excluded from the system availability calculation.

C.2.6.2.3. The Contractor shall immediately communicate unscheduled downtimes in excess of a Government-determined threshold (no fewer than 15 minutes) to MTF pharmacy staff and other parties who have indicated interest in receiving this information. Updates on system availability will be provided at a Government-determined interval and will include an estimate of when the system will once again be available for use. A final notification shall take place to inform users that regular processing has been restored. The communication mechanism shall be provided and maintained by the Contractor.

C.2.6.2.4. The Contractor shall schedule maintenance windows, to the greatest extent possible, to coincide or overlap with Defense Manpower Data Center (DMDC) maintenance windows, as described in TRICARE Systems Manual (TSM) Chapter 3, Section 4.2. The TSM reflects a maximum window within which DMDC scheduled maintenance will occur. Actual planned duration is communicated by DMDC on a weekly basis (See C.11.5.2.). DMDC will attempt to accommodate the Contractor’s needs when establishing a maintenance schedule.

C.2.6.2.5. The Contractor shall notify the Government no less than 72 hours in advance of any planned maintenance window. Such notification shall include MTF pharmacy staff and any other interested parties through the process under C.2.6.2.3.

The Contractor shall accept any one of the multiple identifiers that may be submitted to process claims. Identifiers include but are not limited to DoD ID, social security number (SSN), or DoD Benefits Number (DBN). The primary identifier used by the Contractor shall be the DoD ID, as described in the TSM, and the Contractor’s system shall link the identifier transmitted by the pharmacy with the DoD ID. The Contractor shall dynamically link all variations of patient IDs to ensure a single patient profile, including instances where patients may be eligible under health plans as a result of having more than one sponsor.

The Contractor shall ensure that their system utilizes software which maximizes configurable parameters to allow for changes to be made quickly and efficiently.

C.2.7. DEERS

Verifying Eligibility. The Contractor shall not authorize payment for a prescription prior to verifying eligibility, except at the direction of the Government.

C.2.7.1.1. In some cases, the Government may authorize the Contractor to process one or multiple claims regardless of DEERS eligibility or date of service. Any necessary overrides must be available to allow for real-time electronic claims and paper claims to process at any pharmacy

POS.

C.2.7.1.2. The Contractor shall minimize queries to DEERS for transactions not authorizing payment and as a result of timed-out transactions.

HT940220R0002 Page C6 of C78 Amendment 5

C.2.7.1.3. The Contractor shall monitor DEERS query volumes for all interfaces throughout the period of performance against the projections provided during transition. The Contractor shall investigate the variance in these volumes and revise estimates for future periods of performance annually, or any time actually query volume deviates significantly from the most recent projections (CDRL A090).

Catastrophic Cap and Deductible (CC&D)

C.2.7.2.1. The Contractor shall use the beneficiary’s CC&D status to apply the correct copayment and deductible and perform updates in accordance with TOM Chapter 23, Section 3.

Separate catastrophic caps are maintained for Continued Health Care Benefits Program (CHCBP), in accordance with TOM Chapter 23, Section 3.

C.2.7.2.2. The Contractor shall receive and provide reporting on the maintenance of CHCBP catastrophic caps (CDRL Q120).

C.2.8. Claims Processing Edits

The Contractor shall support claims adjudication rules specific to the POS, including separate rules for different MTF electronic health records (EHR) systems.

The Contractor shall apply comprehensive edits at the point of dispensing in accordance with commercial best practices. New claims shall be screened against the complete patient profile (see C.2.3) and the appropriate benefit design in force for that date and POS. The Contractor shall return appropriate clinical warnings or administrative alerts.

The Contractor shall perform real-time edits that may be specific to DoD and fall outside standard commercial practice, including but not limited to Prescription Monitoring Program, sanctioned providers, safety reviews established through the Uniform Formulary process, and the ability to suppress real-time edits by POS based on Government direction.

The Contractor shall be responsible for processing claims with dates of service prior to the start of this contract. This includes initial submission of claims, and also any adjustments, corrections, cancellations or recoupments. The Contractor shall perform all necessary research to process the claim according to benefit design and formulary restrictions in effect on the date of service.

At the Government’s direction, the Contractor shall process any claim or prescription order. The Contractor shall apply any required overrides to allow the prescription to process successfully, resulting in a “paid” status.

State of Emergency (SOE) Declarations

C.2.8.6.1. The Contractor shall monitor SOE 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 SOE. The recommendation will include the designated ending date for the SOE.

HT940220R0002 Page C7 of C78 Amendment 5

C.2.8.6.2. 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. The Government may also direct the Contractor to implement these measures for specific areas outside of a declared SOE.

C.2.8.6.3. The TMOP shall not ship medications to areas under declared emergency without confirming that delivery by carrier and receipt by beneficiary, is possible. For packages shipped prior to the emergency declaration that were reported lost or missing, the Contractor shall immediately ship the replacement to the beneficiary’s alternate address and refund copay for the lost shipment upon request.

C.2.8.6.4. The Contractor shall provide standard emergency operating procedures which address the following:

• Avoid waste when shipping to areas where there is disaster, including holding shipments, confirming carrier delivery availability, and verifying current beneficiary location.

• Facilitate beneficiary access to medications during a declared emergency at both retail and mail POS, including but not limited to bypassing edits, replacing lost shipments, and shipping to alternate addresses. Facilitating access at MHS GENESIS POS will be limited to bypass of edits.

• Maintaining communication channels to keep stakeholders informed, including:

o Beneficiaries: how they can receive their medications, in coordination with DHA

Communications.

o MTFs: possible patient movement, use over override codes, and how to transfer prescriptions o Retail Network: possible patient influx (e.g., local MTF being incapacitated) o DHA leadership: continual monitoring of SOE and recommendations for extension or early termination of emergency operation procedures

• Identify pharmacies impacted and advise of open network pharmacies within the impacted area

C.2.8.6.5. After an event, the Contractor shall provide reporting on the overrides that were granted under the Emergency procedures (CDRL R070). An event may be comprised of a number of individual Emergency Declarations (i.e., a hurricane that impacts a number of counties and states).

C.2.9. Other Health Insurance (OHI)

The Contractor‘s OHI file shall be the system of record for OHI. In all cases where possible OHI is identified, including but not limited to leads provided by the Managed…