HT940220R000200001 TPharm5 Amendment 00001 20200810.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.

1WPW1

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.is 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

The above numbered solicitation is amended as set forth in Item 14. The hour and date specified for receipt of Offers

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.

000001

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

X

9B. DATED (SEE ITEM 11)

07/13/2020

07/31/2020

Amendment 1 to HT940220R0002 includes revisions made to Section C - STATEMENT OF WORK, Section F - DELIVERIES OR PERFORMANCE, Section G - CONTRACT ADMINISTRATION, Section H - SPECIAL CONTRACT REQUIREMENTS, Section I - CONTRACT CLAUSES, Section J - LIST OF ATTACHMENTS, Section K - REPRESENTATIONS & CERTIFICATIONS, Section L - INSTRUCTIONS, CONDITIONS & NOTICES TO OFFERORS, and Section M - EVALUATION FACTORS FOR AWARD.

08/10/2020

HT940220R000 2 of 5 Amendment 1

1. Changes to SF-33 which:

a. Populate Block 9 to reflect (1) the number copies listed in L.3.2. Table L-1 and (2) the location of depository.

b. Populate Block 12 to reflect that the offeror’s proposal shall be valid for 300 days from the date of submission.

2. Section C.

a. Revises C.8.7.16. Corrects the reference to Electronic Prior Authorizations (ePA) to cite C.11.15.9.

b. Revises C.8.10.2.3. Corrects the reference to administrative override to cite C.8.10.2.1.

3. Section F. Revise F.3.5.6 to add CDRL R170, Mission-Essential Contractor Services Plan.

4. Section G, Revise G.3.6.1 [1st sentence]

FROM: G.3.6.1. Retail and Unreplenished Specialty Pharmacy Benefit Payment. The Government will bear the cost of retail prescriptions and those specialty prescriptions not replenished by the NPV dispensed under this contract.

TO: G.3.6.1. Retail and Unreplenished Specialty Pharmacy Benefit Payment. The Government will bear the cost of retail prescriptions and those specialty prescriptions not replenished by the NPV dispensed along with applicable dispensing fees under this contract.

5. Section H.

a. Revises H.3.3.3 to better describe claims which are excluded from the calculation of the Specialty Network Cost Control Incentive.

FROM: H.3.3.3. Exclusions. The following claims are excluded from this guarantee:

• Medications replenished by the Government.

• Medications procured by the Contractor under the MPPP.

TO: H.3.3.3. Exclusions. The following claims are excluded from this guarantee:

• Claims that meet the exclusion criteria per H.3.2.3.

• Medications replenished by the Government.

• Medications procured by the Contractor under the MPPP.

b. Revises H.9.2. Corrects reference to claims processing performance standards to cite H.9.2.7.

6. Section I.

a. Adds FAR 52.204-25 Prohibition on Contacting for Certain Telecommunications and Video Surveillance Services Equipment (AUG 2019).

b. Adds DFARS 252.237-7023 Continuation of Essential Contractor Services (OCT 2010).

7. Section J.

a. Revises Attachment J-1 Definitions, to define “Active User” of the pharmacy benefit.

b. Revises Attachment J-6 CDRL Cover Sheet, to add CDRL R170, Mission-Essential Contractor Services Plan.

HT940220R000 3 of 5 Amendment 1

8. Section K. Adds FAR 52.204-24 Representation Regarding Certain Telecommunications and Video Surveillance Services or Equipment (DEC 2019).

9. Section L.

a. Adds DFARS 252.237-7024 Notice of Continuation of Essential Contractor Services (OCT 2010)

b. Revises paragraph L.3.2, Table L-1 Proposal Preparation Checklist

(1) Volume 1 Administrative Documents - Revises guidance regarding the Offeror’s Financial Viability Information in TAB D, to indicate they should be submitted in electronic form only.

(2) Volume 2 Technical Proposal - Adds a reference the offeror’s submission of their plan to provide Mission-Essential Contractor Services, to be listed as TAB D, Appendix 1.

(3) Volume 3 Past Performance - Revises guidance regarding the Offeror’s Past Performance in TAB G, to indicate this information should be submitted in electronic form (in PPI) and does not apply to page count limitation.

c. Revises L.4.2

FROM: L.4.2. Table of Contents. Each volume of the proposal should contain a detailed table of contents. All pages of each factor should be sequentially numbered. If more than one binder is used, the complete table of contents shall be included in each.

TO: L.4.2. Table of Contents. Each volume of the proposal should contain a detailed table of contents. All pages of each volume shall be sequentially numbered. If more than one binder is used for a volume, the complete table of contents for that volume shall be included in each binder.

d. Adds L.5.5.5 as follows:

L.5.5.5. MTF Pharmacy Claims

L.5.5.5.1. The offeror shall describe its approach to processing MTF pharmacy claims.

This includes maintaining separate adjudication rules for claims submitted through MHS GENESIS and CHCS.

L.5.5.5.2. The offeror shall demonstrate its approach to performing corrections for claims submitted through CHCS.

e. Revises L.5.8.5.2.

FROM: L.5.8.5.2. The offeror shall describe its approach to providing a comprehensive Continuity of Operations Plan (COOP).

TO: L.5.8.5.2. The offeror shall describe its approach to providing a comprehensive Continuity of Operations Plan (COOP) to provide all services described in Section C.

The offeror will separately describe its plan (TAB D, Appendix 1) to provide the specific Mission Essential Services listed in Attachment L-28 should these services be required in accordance with DFARS 252.237-7023.

HT940220R000 4 of 5 Amendment 1

f. Revises the L.5.9 table to reflect the section designations as follows:

Section L Section M Section C

Subfactor 1-1

L.5.5.1. M.4.4.1. C.2.

L.5.5.2. M.4.4.2. C.3.

L.5.5.3. M.4.4.3. C.9.

L.5.5.4. M.4.4.4. C.11.

L.5.5.5. M.4.4.5. C.5.

Subfactor 1-2 L.5.6.1. M.4.5.1 C.6.

Subfactor 1-3 L.5.7.1. M.4.6.1. C.4.

L.5.7.2. M.4.6.2. C.7.

L.5.7.3. M.4.6.3. C.8.

Subfactor 1-4 L.5.8.1. M.4.7.1. C.10.

L.5.8.2. M.4.7.2. C.12.

L.5.8.3. M.4.7.3. C.13.

L.5.8.2. M.4.7.2. C.14.

L.5.8.3. M.4.7.3. C.15

g. Revises L.8.3.2. Corrects a reference to offerors submitting their Negotiated Specialty Retail

Replenished Dispensing Fees to correctly cite Attachment L-3.

h. L. 9. Section L Attachments.

• Revises L.1.1 List of Data Packages (Rev 1) corrects title of Data Package 8

• Revises L.1.4 Data Sharing Agreement Application - DSAA (Rev 1) to clarify required content

• Provides L-2 Retail Network Guarantee Reimbursement Table

• Provides L-3 Specialty Guarantee Reimbursement Table

• Revises L-18, CDRL Supplemental Bid Schedule (Rev 1) add CDRL R170 and provides a printable format

• Revises L-20, Specialty Drug List (Rev 1) to correct the drugs listed

• Revises L-25, Total Evaluated Cost Spreadsheet (Rev 1) - to make an administrative correction and to provide a printable format

• Adds Attachment L-27, Testing Processes for MHS GENESIS

• Adds Attachment L-28, Mission Essential Contractor Services, dated July 29, 2020

10. Section M,

a. Adds M.4.5.5. as follows:

M.4.4.5. MTF Pharmacy Claims

M.4.4.5.1. The offeror’s proposal will be evaluated based on its approach to processing MTF pharmacy claims. This includes the proposed approach to maintaining separate adjudication rules for claims submitted through MHS GENESIS and CHCS.

M.4.4.5.2. The offeror’s proposal will be evaluated based on its approach to performing corrections for claims submitted through CHCS.

HT940220R000 5 of 5 Amendment 1

b. Revises M.4.7.4.2:

FROM: M.7.4.2. The offeror’s proposal will be evaluated based on its approach to providing a comprehensive Continuity of Operations Plan (COOP).

TO: M.4.7.4.2. The offeror’s proposal will be evaluated based on its approach to providing a comprehensive Continuity of Operations Plan (COOP) for all services described in Section C. The offeror will also be evaluated based on its submitted plan (TAB D, Appendix 1) to provide the specific Mission Essential Services listed in Attachment L-28 should these services be required in accordance with DFARS 252.237-7023.

11. A conformed copy for the solicitation is attached. Changes to the paragraphs identified above are marked with 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

1 259

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

1600 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

10/16/2020 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 1

ITEM NO. SUPPLIES/SERVICES QUANTITY UNIT UNIT PRICE AMOUNT

NAME OF OFFEROR OR CONTRACTOR

2 262

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 322300 EA TRICARE Only Eligible (Option Line Item)

1004 Specialty Network Claims 478900 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 ...

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

NAME OF OFFEROR OR CONTRACTOR

3 262

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 ...

$_____.00 $__________.00

$_____.00 $__________.00

$_____.00 $__________.00

$_____.00 $__________.00

$_____.00 $__________.00

$_____.00 $__________.00

$_____.00 $__________.00

NAME OF OFFEROR OR CONTRACTOR

4 262

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

$__________.00$__________.00

$________.00 $__________.00

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

$__________.00 $__________.00

NAME OF OFFEROR OR CONTRACTOR

5 262

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 349400 EA TRICARE Only Eligible (Option Line Item)

2004 Specialty Network Claims 519200 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 ...

$__________.00$________.00

$__________.00$_______.00

$__________.00$_______.00

$__________.00$________.00

$__________.00$_______.00

$__________.00$_______.00

$__________.00$_______.00

$__________.00$_______.00

NAME OF OFFEROR OR CONTRACTOR

6 262

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 ...

$__________.00$_______.00

$__________.00$_______.00

$__________.00$_______.00

$__________.00$_______.00

NAME OF OFFEROR OR CONTRACTOR

7 262

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 380400 EA TRICARE Only Eligible (Option Line Item)

3004 Specialty Network Claims 565300 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

$__________.00$__________.00

$__________.00$__________.00

$__________.00$_______.00

$__________.00$______.00

$__________.00$______.00

$__________.00$______.00

$__________.00$______.00

NAME OF OFFEROR OR CONTRACTOR

8 262

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 ...

$______.00 $__________.00

$______.00 $__________.00

$______.00 $__________.00

$______.00 $__________.00

$_____.00 $__________.00

$______.00 $__________.00

NAME OF OFFEROR OR CONTRACTOR

9 262

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 ...

$______.00 $__________.00

$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

10 262

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 415500 EA TRICARE Only Eligible (Option Line Item)

4004 Specialty Network Claims 617500 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 ...

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

NAME OF OFFEROR OR CONTRACTOR

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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 ...

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

$__________.00 $__________.00

NAME OF OFFEROR OR CONTRACTOR

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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 454900 EA TRICARE Only Eligible (Option Line Item)

5004 Specialty Network Claims 676000 EA Continued ...

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

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

$__________.00 $__________.00

$__________.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

NAME OF OFFEROR OR CONTRACTOR

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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 ...

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

$__________.00 $__________.00

NAME OF OFFEROR OR CONTRACTOR

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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 ...

$_______.00 $__________.00

$______.00 $__________.00

$__________.00 $__________.00

$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 498800 EA TRICARE Only Eligible (Option Line Item)

6004 Specialty Network Claims 741400 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 ...

$__________.00 $__________.00

$__________.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

$_______.00 $__________.00

$______.00 $__________.00

$______.00 $__________.00

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 ...

$_______.00 $__________.00

$______.00 $__________.00

$_______.00 $__________.00

$______.00 $__________.00

$______.00 $__________.00

NAME OF OFFEROR OR CONTRACTOR

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CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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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

$__________.00 $__________.00

$__________.00 $__________.00

NAME OF OFFEROR OR CONTRACTOR

18 262

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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

7003 Specialty Network Claims 547600 EA TRICARE Only Eligible (Option Line Item)

7004 Specialty Network Claims 814000 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 ...

$______.00 $__________.00

$______.00 $__________.00

$______.00 $__________.00

$______.00 $__________.00

$_______.00 $__________.00

NAME OF OFFEROR OR CONTRACTOR

19 262

CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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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 ...

$______.00 $__________.00

$______.00 $__________.00

$______.00 $__________.00

$__________.00 $__________.00

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

NAME OF OFFEROR OR CONTRACTOR

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CONTINUATION SHEET REFERENCE NO. OF DOCUMENT BEING CONTINUED PAGE OF

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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

HT940220R0002 Page C1 of C79 Amendment 1

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).

HT940220R0002 Page C2 of C79 Amendment 1

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.

HT940220R0002 Page C3 of C79 Amendment 1

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

HT940220R0002 Page C4 of C79 Amendment 1 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.

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.

HT940220R0002 Page C5 of C79 Amendment 1

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 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.

HT940220R0002 Page C6 of C79 Amendment 1

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.

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&Dstatus 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

HT940220R0002 Page C7 of C79 Amendment 1

"Emergency Refill Too Soon Procedures" for areas placed under a SOE. The recommendation will include the designated ending date for the SOE.

C.2.8.6.2. Upon approval by the Government, the Contractor shall have the…