TPharm5 Section C Draft RFP2 2020-4-6.docx

SECTION C

STATEMENT OF WORK

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, their spouses and children, including TRICARE for Life beneficiaries. The TRICARE Pharmacy Program is authorized under 10 USC 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 or utilization review requirements to assure medical necessity, 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 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.

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 collaborative management and quality control for all services and functions.

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

Government Furnished Information The Contractor shall connect to 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 TMOP replenishment and for adjudicating MTF CHCS claims.

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

· Pharmacy Data Warehouse

· Composite Healthcare System (CHCS)

· Forensic Toxicology Drug Testing Laboratory Information Management System

· 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.

The Government will provide a monthly beneficiary address file 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 Pharmacy Data Warehouse 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 and medical necessity determinations for the past two year period. The Government (via the outgoing contractor) will also provide an OHI data file.

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.

The Contractor shall utilize the current version of the TRICARE Program Manuals T-2017, published at Attachment J-3, line 11. The manuals are applicable in their entirety, unless a specific exception is identified in the TRICARE Pharmacy Contract (TPharm5) Manual Version and Exceptions Table (Attachment J-6).

The Manual Version and Exceptions document will be continuously and separately maintained by the Government and provided to the Contractor at a minimum of monthly.

The COR and Contractor shall routinely review proposed and published manual changes. When a new manual change is published (identified as with a Change number and date), the Government shall update the Manual Version and Exceptions document to include the change.

0. The Contractor has ten (10) business days from receipt of notification of an upcoming change to notify the Government, in writing, of any objection to the incorporation of the change(s), or portion there-of, stating the basis of this objection. Upon receipt of such notification, The Government will have 30 days to negotiate in good faith a bilateral agreement to the table and the manual change in question will be held in a pending status until the issue is resolved by mutual agreement of the Government and Contractor.

0. If no such objection is filed, the change(s) will be deemed to apply to the Contractor at the end of the 10-day period referenced above and will be included in a supplemental (bilateral) agreement. Supplemental agreements to memorialize the most recent version of the manuals will occur no more frequently than four times per year.

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.

General Claims Processing.

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

Unless stated otherwise, claims adjudication includes processes outlined in C.2, consisting of eligibility check, application of the correct copayment, identification of other health insurance (OHI), benefit design edits, drug utilization review and application of catastrophic cap and deductible updates.

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

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.

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

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. The system is considered to be unavailable when the failure rate for claims exceeds 25% for at least 30 minutes.

The Contractor shall provide reporting on system availability performance (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.

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

The Contractor shall immediately communicate unscheduled downtimes in excess of 30 minutes to the Government, including MTF pharmacy staff and other parties who have indicated interest in receiving this information. Updates on system availability will be provided hourly and will include an estimate of when the system will once again be available for use. The communication mechanism shall be provided and maintained by the Contractor.

The Contractor shall schedule maintenance windows, to the greatest extent possible, to coincide or overlap with DMDC maintenance windows, as described in TSM Chapter 3, Section 4.2. (Note: 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.

The Contractor shall notify the Government no fewer than 72 hours in advance of any planned maintenance window. Such notification shall include MTF pharmacy staff and any other interested parties.

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 at the lowest possible cost to the Government.

DEERS

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

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 point of service.

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

The Contractor shall monitor DEERS query volumes 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 The Contractor shall use the beneficiary’s catastrophic cap and deductible (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.

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

Claims Processing Edits The Contractor shall support claims adjudication rules specific to the point of service, including separate rules for different MTF electronic health records 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 point of service. The Contractor shall return appropriate clinical warnings or administrative alerts.

The Contractor shall also perform other 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 point of service 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 Declarations.

The Contractor shall monitor State of Emergency 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 state of emergency. The recommendation will include the designated ending date for the state of emergency.

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 State of Emergency.

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, missing, the Contractor shall immediately ship replacement to the beneficiary’s alternate address and refund copay for the lost shipment upon request.

The Contractor shall provide standard emergency operating procedure 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 point of service, including but not limited to bypass edits, replacing lost shipments, and shipping to alternate addresses. Facilitation of access at MHS GENESIS points of service will be limited to bypass of edits.

· Maintaining communication channels to keep stakeholders informed, including:

· Beneficiaries of how they can receive their medications, in coordination with DHA Communications.

· MTFs of possible patient movement, use over override codes, and how to transfer prescriptions

· Retail Network of possible patient influx (e.g., local MTF being incapacitated)

· 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 After an event, the Contractor shall provide reporting on the overrides that were granted under the Emergency procedures (CDRL R130). An event may be comprised of a number of individual Emergency Declarations (i.e., a hurricane that impacts a number of counties and states).

Other Health Insurance 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 Care Support Contractors (MCSC), pharmaceutical manufacturers, claim forms, beneficiary declarations, and Contractor’s internal files, the Contractor shall investigate and develop OHI records in accordance with TOM, Chapter 23, Section 3, TOM Chapter 10, Section 5, and TRM, Chapter 4.

The Contractor shall implement processes to maximize the identification of OHI, including but not limited to utilizing commercial services or data sources.

In the event that OHI records in DEERS are inconsistent with the Contractor’s system, the Contractor shall, as part of the claims adjudication process, utilize logic to determine which source is the most reliable. Such logic shall take into consideration a number of factors, including but not limited to the completeness of the DEERS OHI record (a complete record vs. a placeholder), the type of benefit associated with the record (medical comprehensive vs. pharmacy), and the age of the record.

When new OHI is identified, the Contractor shall pursue recoupment for past claims and build out the beneficiary’s profile for future claims. (See C.2.8.4.) Post-adjudication, the Contractor shall perform reviews to ensure the claim processed correctly and update either DEERS or their system as necessary to maintain consistency.

The Contractor shall have a mechanism to allow a DEERS OHI record to be bypassed for up to one year based on the beneficiary’s attestation that such OHI does not exist. Claims within that time will continue to process without rejecting for the reported OHI record.

C.2.9The Contractor shall document their policies for the application of OHI information in claims processing including the use of different types of DEERS records and how discrepancies are resolved. This documentation will be made available for the Government’s review upon request.

The Contractor shall provide a reporting to the Government on OHI development (CDRL Q110) and cost avoidance (CDRL Q111).

Claims Processing System Documentation The Contractor shall develop and maintain comprehensive documentation of all aspects of claims processing. This documentation shall include the items listed below as well as any supplemental information provided by the Contractor. The sum of all this documentation shall allow the Government to correctly determine how any given claims processing scenario will adjudicate. Updated versions of any of these documents shall be made available to the Government upon request.

The Contractor shall maintain all payer sheets used in the transmission of DoD claims from all points of service.

The Contractor shall maintain a benefit design document and provide the Government with access to the current version via a web-based platform. The Contractor's presentation of the benefit design within this document shall remain consistent with the elements of the document initially provided by the Government and shall be in a format agreed to by the Government. The benefit design shall contain formulary and benefit restrictions based on beneficiary category, point of service, medication by category, and any other factors, including but not limited to:

· MTF Basic and Extended Core Formularies

· Compound inclusions and exclusions

· Covered OTCs

· Federal Ceiling Price (FCP) Non-Compliant Retail Exclusions

· Non-Formulary Drugs

· Prior Authorization

· Step-Therapy Drugs

· Self-Administered Injectables

· Smoking Cessation Drugs

· Specialty Drugs

· Covered Vaccines

· Non-covered Drugs

· Quantity Limit Restrictions

· Age restrictions Retail Prescriptions Retail Prescription Claims The Contractor shall accept and process all claims for pharmaceutical agents and supplies covered under the TRICARE pharmacy benefit, and purchased from a licensed pharmacy in the 50 United States, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, Northern Mariana Islands, American Samoa and Guam.

Retail claims for covered drugs will be limited by requirements under 10 U.S.C. 1074g, 32 CFR 199.21, and other applicable regulations. Network pharmacies may submit claims for covered supply items using the National Drug Code (NDC) numbers assigned to them.

When access to specific drugs at retail pharmacies is restricted under the law, the Contractor shall facilitate either a change in the beneficiary’s current prescription to an approved pharmaceutical or supply, or shift the beneficiary’s prescription to TMOP. Covered drugs that are restricted at retail and their respective implementation dates are published at in DoD P&T Committee Meeting Minutes (Attachment J-3, Line 1).

Claims received for covered drugs furnished in geographical locations not covered under this contract shall be forwarded to the TRICARE Contractor responsible for processing claims for those locations as specified in the TOM, Chapter 8, Section 2.

The Contractor shall complete real-time, online Coordination of Benefits (COB) in accordance with NCPDP D.0 standards (or most current version) for those claims filled in retail network pharmacies where OHI has been identified, to include Medicare Part D claims. The Government will provide the COB and Medicare Part D billing transaction segments to include the required values. The Contractor is required to track Medicare Part D True Out-Of-Pocket expenses (TROOP) and total drug expenditures for each TRICARE beneficiary who is also enrolled in Medicare Part D. The Contractor shall provide this information to the Centers for Medicare & Medicaid Services (CMS) designated TROOP facilitator.

The Contractor shall reimburse claims in accordance with the TRM, Chapter 4.

TRICARE will act as primary payer for claims submitted by Department of Veteran’s Affairs (VA) pharmacies for beneficiaries who are TRICARE-eligible. The double coverage provisions in TOM, Chapter 23, Section 3 and TRM, Chapter 4 are waived for beneficiaries with Medicare Part D. VA benefits are not considered OHI.

If requested by the beneficiary and allowable under federal and state law, the Contractor may authorize the dispensing of up to a 90-day supply prescription as a single transaction at a retail pharmacy. In these cases, the pharmacy shall collect a copayment for each 30-day increment. The Contractor must make this option available at all retail network pharmacies.

Claims for prescriptions filled but not dispensed shall be reversed within ten (10) calendar days of the date the original claim was submitted. Reversals processed more than ten (10) calendar days after the date the original claim was submitted will require an adjusted or cancelled TED record.

The Contractor shall process batch claims in the most current NCPDP batch format. The Contractor may receive batch claims from a variety of sources (e.g., State Medicaid agencies, clearinghouses, DVA) and the Contractor shall process these claims regardless of the electronic media (e.g., CD ROM, tapes) through which they are submitted. All batch claims shall be processed within 14 days of receipt. The Contractor shall process claims from state agencies in accordance with TRM Chapter 1 Section 20. Notwithstanding the above, Medicaid subrogation electronic batch claims shall be processed within two business days.

Paper Claims The Contractor shall process paper claims submitted by beneficiaries, also known as direct member reimbursement (DMR) claims, and those submitted by pharmacies, known as assignment of benefit claims, in accordance with TOM, Chapter 23, Section 3, Paragraph 1.2 and Chapter 8, Section 1, Paragraph 3.1. The Contractor shall accept claims submitted using any of the specified forms. Electronic submission of paper claims is only allowed under an approved OMB format.

Upon request, the Contractor shall mail the current version of the DD2642 claim form to beneficiaries.

Paper claims for non-network pharmacy services shall be reimbursed in accordance with the TRM, Chapter 1, Section 15, minus applicable copayments and deductibles.

The Contractor shall process these paper claims using the most current NCPDP format.

The Contractor shall monitor paper claims processing and work with retail network pharmacies to reduce the volume of network paper claims. Network pharmacies should be using online coordination of benefits in most cases and the Contractor shall work with any pharmacies with higher than average rates of paper claims to transition them to online processing.

The Contractor shall require all retail network pharmacies to utilize online Coordination of Benefits.

Manual corrections to retail pharmacy claims are not considered paper claims. The Contractor shall not categorize them as paper claims for reporting or billing purposes.

Claims for beneficiaries who are required by their OHI to use their designated mail order pharmacy or other non-network pharmacy are to be processed using network cost shares. Non-network copayments and deductibles are not applicable to these claims.

The Contractor shall routinely audit paper claims to look for scenarios such as high cost claims, high cumulative claims value, and high volume of claims. All such reviews and audits shall be performed at the beneficiary and family level.

Measured on a monthly basis, paper claims shall meet the following minimum standards:

95% of paper claims shall be processed to completion within 14 calendar days of receipt.

100% of paper claims shall be processed to completion within 28 calendar days of receipt.

The Contractor shall provide reporting on paper claims volumes, processing times, denials and appeals (CDRL Q050). Paper claims are considered to be processed to completion as of their TED record Create Date.

For denied paper claims, notification to the beneficiary must be in writing. The notification must explain why the claims were denied and detail the beneficiary's appeal rights.

Under the TRICARE benefit, the Contractor shall not process paper claims for prescriptions filled at MTF pharmacies. If necessary, the Contractor may forward the claims to its commercial services section for review as a claim payable by a commercial insurance plan.

Retail Pharmacy Network The Contractor shall establish and maintain a retail pharmacy network throughout the 50 United States, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and Guam. The Contractor shall provide network retail pharmacy services in American Samoa and the Northern Mariana Islands when they become eligible.

Retail Network Access. The Contractor's retail pharmacy network shall provide at least one pharmacy within 15 minutes driving time of 90% of the beneficiaries.

Exclusions.

MTF, VA, PHS, and IHS pharmacies shall not be considered as retail network pharmacies for purposes of this requirement.

Beneficiaries residing on military installations shall be excluded from this metric. The Government will provide a list of zip codes of military installations for the Contractor’s use in calculating this metric.

The Contractor shall use commercially available software or web tools to calculate this metric and the methodology shall be made available to the Government for audit upon request.

The Contractor shall provide reports identifying retail network pharmacies and the total network size (CDRL M040) and network access relative to the above metrics (CDRL M041).

All network pharmacies shall be fully licensed in accordance with applicable Federal and State laws and have a current NCPDP number. Pharmacies providing pharmaceuticals solely through internet or mail order pharmacies shall not be included in the retail network. Retail pharmacies who offer to mail prescriptions to beneficiaries as part of their business may be included in the network subject to the retail pharmacy specifications listed herein.

At a minimum, the retail pharmacies shall provide TRICARE beneficiaries the same quality of services provided to beneficiaries of other commercial clients, to the extent allowed by Federal regulation and this contract. The Contractor shall ensure that all pharmacies document the receipt of the medication by the beneficiary or the individual authorized by the beneficiary, in accordance with all applicable State and Federal Laws. The Contractor shall ensure that network pharmacies have procedures to reasonably assess the validity of prescriptions ordered by telephone.

Changes to the Retail Pharmacy Network The Contractor shall have a plan for communicating to beneficiaries when a pharmacy is removed from the network. As part of the plan, the Contractor shall do the following:

· Provide the Government with the names of all pharmacies selected for removal from the network at a minimum of 60 days prior to the effective date of the changes.

· Identify and provide advance notification to beneficiaries who have filled prescriptions at the designated pharmacies during the previous six (6) months. The Contractor shall ensure that the beneficiary receives the letter at a minimum of 30 days prior to the effective date of the change.

· Provide the Government with samples of all beneficiary correspondence related to the change in the network for comment. The Government shall have no less than 14 days to review.

· Make changes to the plan as necessary to ensure successful communications with the all beneficiaries and minimize disruption of therapy.

In situations where a pharmacy fails to meet credentialing standards or there is indications of potential fraud that does not meet the standard requirements for case development per TOM Chapter 13, the Contractor may remove the pharmacy from the network without providing advance notification to the Government or beneficiaries. For other situations that justify short-notice removal of a pharmacy, the Contractor shall contact the Government for approval. The Contractor shall notify the impacted beneficiaries within 14 days after the pharmacy is removed.

Specialty Pharmaceuticals The Government will provide an initial list of drug considered for the specialty pharmacy program. The Contractor shall propose updates to the list based on changes in the market, evolution of clinical practices, limited access, cost effectiveness, and clinical support considerations.

The Contractor shall provide the methodology under which drugs are evaluated and proposed for the addition or removal from the program.

Accreditation.

The network specialty pharmacy(ies) shall maintain accreditation by a nationally recognized external accrediting body (e.g., URAC, ACHS, CPPA).

The Contractor shall ensure that network specialty pharmacies stay current with established regulatory requirements and practice standards governing supply chain and medication provision.

The Contractor shall provide notification to the Government of any changes to the network per C.3.3.8.

Access.

The Contractor shall maximize the extent to which beneficiaries are able to obtain specialty pharmaceuticals through nationally accredited specialty pharmacies, when not dispensed by an MTF pharmacy, such that all covered specialty drugs, including limited distribution drugs, are accessible to beneficiaries at in-network cost shares when appropriately prescribed.

The Contractor shall provide patient and/or prescriber education on obtaining certain pharmaceuticals that may have access restrictions or manufacturer supported medication assistance or delivery programs that align with or differ from those programs offered under the network specialty pharmacy(ies).

The Contractor shall facilitate the transfer of specialty prescriptions from non-specialty pharmacies or TMOP to network specialty pharmacy(ies) when appropriate to support access to specialty pharmaceuticals and minimize beneficiary confusion.

Patient Support. The Contractor shall ensure that the network specialty pharmacies deliver care in accordance with nationally accredited specialty pharmacy standards. At a minimum, these programs shall provide medication administration support (e.g. patient education, call center support, and therapy evaluation) that limits risk to the patient, maximizes adherence, well-being and patient satisfaction, and provides delivery management services to include timely delivery of medications and waste prevention. The Contractor shall ensure that the patient has access to accompanying supplies (e.g. for administration, use, disposal, etc.) for drugs dispensed at network specialty pharmacies.

Programmatic Support. The Contractor shall optimize the specialty program in the areas of cost controls, utilization strategies and incorporation of commercial best practices. Utilization strategies will align with those noted under C.7.2.1.

Replenishment.

The Contractor shall maximize opportunities for replenishment of designated specialty drugs.

Replenishment will be owed only for; 1) medications dispensed to TRICARE eligible beneficiaries; 2) medications available for replenishment; 3) medications which are not acquired through the MPPP.

Requesting replenishment shall follow C.6.8. Any deviation in ordering product for replenishment from the NPV shall be requested per CDRL D011. The Contractor shall also monitor availability for cost effective products for replenishment and provide recommendations to the government per CDRL W011.

The replenishing pharmacy(ies) will utilize their own process for validating replenishment received for accuracy and completeness and will account for replenishment still owed.

Not all specialty drugs will be replenished due to limited distribution channels or other factors which may prevent access through the NPV. For non-replenished medications, the costs will be reimbursed and the Contractor’s cost control measures will be incentivized per the specialty network guarantee included in their proposal (H.3.3).

Non-specialty drugs if dispensed from specialty network pharmacies will follow retail prescriptions claims processing per C.3.1.

The Contractor may offer cost saving or sustainment opportunities per C.6.8.20. Opportunities shall be accounted for in CDRL R140.

Reporting. The Contractor shall provide a report on the dispensing of specialty prescriptions and clinical services provided (CDRL Q150).

MTF Pharmacy Claims The Contractor shall support claims submissions from MTF pharmacies running two different electronic health records (EHR) systems:

· Composite Health Care System/AHLTA (CHCS)

· MHS GENESIS

The Contractor shall support unique submission methods and claims processing rules for each system.

MTF CHCS Claims The Contractor shall connect to the CHCS as described in Section C.11.7.3 until all remaining sites are transitioned to MHS GENESIS and the Government notifies the Contractor that support for CHCS is no longer needed.

Claims shall be processed using the CHCS business rules. CHCS is a legacy system that cannot support commercial standards so the Contractor must apply the CHCS business rules as prescribed.

MTF dispensing transactions are based on NCPDP D.0. The D.0 format used by the MTFs does not include the Coordination of Benefits segment.

In addition to a DEA Number or NPI, the Contractor shall accept provider SSN on MTF claims.

Formulary edits are not applicable.

The Contractor shall perform ProDUR on the inbound dispensing transactions.

The Contractor does not create TEDs for these claims.

The Contractor shall accept and log all data provided on transactions. All transactions shall be transmitted to the Pharmacy Data Warehouse (PDW).

The Contractor shall not perform DEERS eligibility checks for MTF claims. The MTF assumes responsibility for eligibility; therefore, the Contractor will process the claim regardless of eligibility status.

The Contractor shall support messaging to the MTF and handling of rejected claims to the MTF that varies from that used by the commercial network. The Contractor shall accept all CHCS claims and post them to the patient profile.

· Validity Rejects: The Contractor shall not reject MTF claims due to missing or invalid data. The Contractor will follow the processes outlined in C.5.3 to correct and resubmit the claim. For patient safety reasons, all claims must be successfully resubmitted, posted to the patient profile and transmitted to the Pharmacy Data Warehouse (PDW), unless the Contractor is notified by the MTF to allow the reject to remain on the patient profile.

· ProDUR Alerts: The Contractor shall not reject MTF claims for ProDURs but will instead return custom ProDUR alert messaging. The MTF will respond to the alert by either cancelling the prescription or entering an override code. The Contractor will receive a reversal if the prescription is cancelled, but if the MTF enters an override code, no additional message will be sent to the Contractor. MTF claims resulting specific ProDUR Alerts will be included on the Data Integrity Report described in C.5.2.12.

If an ingredient cost of a penny ($0.01) is submitted by the MTF, the Contractor will recalculate the ingredient cost primarily using the medical pricing catalog supplied by DLA-TS, or using AWP as a secondary source. NDCs received from CHCS are representative and may not reflect the medication actually dispensed so the Contractor shall price the claim using the medical pricing catalog lowest cost entry within the GCN of the submitted NDC.

For claims priced from either the medical pricing catalog or AWP, the Contractor shall apply a regional discount established by DLA-TS, based on the NCPDP Pharmacy ID. If the ingredient cost submitted by the MTF is greater than a penny ($0.01), the Contractor shall post the claim and no regional discount is applied.

MTF Data Integrity Reviews The Contractor shall conduct reviews of MTF pharmacy claims data, excluding claims received from the MHS GENESIS, and perform the following processes to identify and resolve issues specific to MTF claims. MHS GENESIS claims are subject to the reviews under C.10.2.1.

The outgoing contractor will provide an initial list of MTF pharmacy contacts to the incoming contractor. The Contractor shall update as needed and send quarterly updates to the DHA POSC.

The Contractor shall provide a daily report of MTF validity rejects (CDRL D020). Claims submitted using MHS GENESIS shall not be included in this report. The reports shall be broken out by MTF and sent to the pharmacy contact at each submitting MTF. A copy of the daily report shall also be provided to DHA. The MTF pharmacy will have three (3) business days to correct these claims. The MTF may reverse the claim entirely or reverse and resubmit the corrected claim. After allowing three (3) business days for the MTF to correct any errors, the Contractor shall undertake retroactive claims correction in their system to correct the remaining errors and ensure that the claims reflect a paid status. This shall be completed within two (2) business days. The Contractor shall continue to work the claim until it is posts to the profile, is reversed by the MTF, or the MTF notifies the Contractor to take no further action. The Contractor shall ensure that 100% of issues have been addressed within the aforementioned time period.

In the event that the Contractor’s resubmission of a previously rejected MTF claim results in a DUR Interaction Severity Level 1, the Contractor shall contact the clinical staff at the submitting MTF by phone within one (1) hour. For all such situations, the Contractor shall keep a log that will be made available for the Government’s review upon request. At minimum, the log shall document the identifying information of the pharmacy, prescription and beneficiary and the dates and times of the original reject, the DUR and the call communicating the safety warning to the MTF.

The Contractor shall produce a weekly report of all paid MTF claims exceeding an established pricing threshold determined by the Government (CDRL W021). This threshold shall be subject to change. Claims submitted using MHS GENESIS shall not be included in this report. If the Contractor determines that the price is reasonable based on quantity and days supply, consistent with the medical pricing catalog, and consistent with the standard dose for that medication, the claim shall not be included on the report to the MTF and no further action is required. The Contractor shall run the report seven (7) calendar days after the close of the reporting period to allow for time for claims to be corrected by the MTF. The report shall be provided to the submitting MTF, which has five (5) business days to correct any of these claims. After five (5) business days, the Contractor shall review all claims in this report that have not been reversed or resubmitted by the MTF. For the remaining claims, the Contractor shall contact the submitting MTF to troubleshoot the claim, determine the cause of the error, and then correct the error on the claim within two (2) business days. The Contractor shall ensure that 100% of issues have been addressed within the aforementioned time period.

The Contractor shall provide a Data Integrity report to the MTFs on a weekly basis (CDRL W020). The Contractor shall run the report seven (7) calendar days after the close of the reporting period to allow for time for claims to be corrected by the MTF. Claims submitted using MHS GENESIS shall not be included in this report. This report shall include paid MTF claims which generated the following ProDUR warnings:

· High Dose Alerts - All prescriptions processed by MTF pharmacies where the prescription exceeds daily maximum allowable dosage for a medication, as determined by First Databank (FDB). The daily dosage is calculated by dividing the quantity dispensed by the days' supply.

· Incorrect Quantity - Example: Asmanex package size is one, site enters 30 in the quantity field, the adjudication system will calculate 30 inhalers due to the unit of measure being ea, the price will also be calculated incorrectly based on the incorrect quantity dispensed 30x $28.84= $865.20.

· Incorrect Days Supply - Example: Site enters one day supply for Doxycyline 100mg qty 180.

· Invalid Provider The report shall be provided to the submitting MTF, which has five (5) business days to correct any of these claims. After five (5) business days, the Contractor shall review all claims in this report that have not been reversed or resubmitted by the MTF. For the remaining claims, the Contractor shall contact the submitting MTF to troubleshoot the claim, determine the cause of the error, and then correct the error on the claim within two (2) business days. The Contractor shall ensure that 100% of issues have been addressed within the aforementioned time period.

The Contractor shall also provide monthly summary reports to the Government on MTF rejections (CDRL M070), high cost claims (CDRL M072) and data integrity edits (CDRL M071), to allow the Government to monitor the reported claims and their resolution rates. Claims submitted using MHS GENESIS shall not be included in this report.

MHS GENESIS Claims MHS GENESIS is the new EHR replacing CHCS at all MTFs. MHS GENESIS is a commercial standard EHR and processes claims in NCPDP D.0 format (or the most current standard). It is supported by the Defense Healthcare Management System Modernization (DHMSM) contractor. MTFs will continue to transition to the new system until all MTFs are using MHS GENESIS. The Contractor shall connect to sites using MHS GENESIS as described in Section C.11.7.4.

The Contractor shall review any changes to claims processing parameters with the Government before they are implemented, including any NCPDP mandated changes to transactions format, such as changes to reject codes and overrides.

Claims shall be processed using business rules for MHS GENESIS claims, which include the benefit design (including P&T guidance described in C.6.8.20.7) and other documentation (e.g., MTF Set-Up). The Government may direct specific changes to MHS GENESIS business rules as appropriate.

At the direction of the Government, the Contractor shall support coordination of benefits for MHS GENESIS claims. The business rules governing this process may vary from standard commercial practices.

The Contractor shall not perform DEERS eligibility checks for MTF claims. The MTF assumes responsibility for eligibility; therefore, the Contractor will process the claim regardless of eligibility status.

The Contractor shall maintain system documentation, as described in C.2.10.

An interface control document shall be coordinated with the DHMSM Contractor and approved by the Government.

MHS GENESIS claims will utilize a full range of commercial edits, with some exceptions as defined here and in the Edit Set-Up documents. All transactions shall be transmitted to the Pharmacy Data Warehouse (PDW).

The Contractor shall adjudicate all MHS GENESIS claims and shall reject claims that do not pass edits. The Contractor may return a paid claim with advisory messaging in lieu of rejection or exclude specific drugs from such rejects as directed by the Government. The Government may identify specific information to be included in the messaging for advisories or rejects. Commercial standard edits shall apply unless otherwise indicated.

The Contractor shall accept ingredient cost submitted on the claim for MHS GENESIS claims. No adjustments or discounts shall be applied.

The Contractor shall monitor MHS GENESIS rejects and, on a weekly basis, report NDCs which trigger rejects in the indicated categories. (CDRL W030) The Contractor shall coordinate with DHA and/or the MHS GENESIS Contractor to ensure alignment between their drug file and that used by MHS GENESIS, including the handling of new and termed NDCs.

Mail Order Pharmacy Mail Order Pharmacy Prescriptions The Contractor’s mail order facility shall dispense and deliver medications to TRICARE beneficiaries consistent with the requirements that apply to the overall standard operations of TRICARE Mail Order Pharmacy (TMOP) outlined below. For beneficiaries in deployed theaters of operation, the Contractor shall dispense medications as indicated in Section C.6.7.

The Contractor shall accept prescription orders at TMOP by written (original or facsimile), electronic (supporting digital signature including e-prescribing), or telephonic submission.

Prescriptions should be written by healthcare providers licensed in the U.S with prescriptive authority as delegated by state and federal law.

The Contractor shall have procedures in place to reasonably assess the validity of prescription orders.

For all medications dispensed through TMOP, the Contractor’s tracking and dispensing procedures shall comply with Federal and State law and all applicable state board of pharmacy requirements.

For beneficiaries receiving prescription medications through the TMOP, the Contractor shall provide 24 hours a day, 7 days a week access to a pharmacist by phone.

The Contractor shall not collect sales tax on prescriptions dispensed by TMOP.

A beneficiary with OHI cannot use TMOP, unless one of the following exceptions applies:

1. The OHI does not cover the prescribed agent, either by the benefit design or denied coverage review

2. The beneficiary has exhausted the benefits under the OHI.

Under these exceptions, to receive TRICARE coverage of pharmaceuticals dispensed through the TMOP, beneficiaries with OHI must submit documentation to the Contractor showing the OHI does not cover the prescribed item, or documentation such as an Explanation of Benefits (EOB) indicating their coverage has been exhausted. In cases where the Contractor is also the PBM for the OHI, it may provide such documentation in place of the beneficiary. The Contractor will then update the beneficiary’s profile with this information and process the prescription(s) accordingly.

TMOP prescription processing and written notification of denied orders shall meet the following minimum standards:

98% of Mail Order prescriptions not requiring intervention or…