J-20 Price Evaluation Template_Amend 0002.xlsx

XLSX spreadsheet 28 KB Posted Oct 26, 2022

Attached to: TRICARE Dental Program 6 (TDP6) Request for Proposal (RFP) Federal contract opportunity
Solicitation number: HT9402-22-R-0001
Issued by: Defense Health Agency

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Other files for this federal contract opportunity

Other files attached to TRICARE Dental Program 6 (TDP6) Request for Proposal (RFP), newest first.
File	Type	Posted
HT940222R0001_Amend0003.pdf	PDF	May 4, 2023
HT940222R0001_Conformed_Amend 0002.pdf	PDF	Oct 26, 2022
Industry QA_Amend 0002.pdf	PDF	Oct 26, 2022
HT940222R0001_Amend 0002.pdf	PDF	Oct 26, 2022
J-20 Price Evaluation Template_Amend 0001.xlsx	XLSX spreadsheet	Oct 21, 2022
HT940222R0001_Amend 0001.pdf	PDF	Oct 21, 2022
HT940222R0001_Conformed_Amend 0001.pdf	PDF	Oct 21, 2022
Industry QA_Amend 0001.pdf	PDF	Oct 21, 2022
HT940222R0001.pdf	PDF	Sep 29, 2022
TDP6 J Attachments.zip	ZIP file	Sep 29, 2022
TDP6 CDRLs.zip	ZIP file	Sep 29, 2022

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Section B

Solicitation Number: HT9402-22-R0001

Service: TRICARE Dental Plan 6

Offeror:

Price Evaluation Template

Section B - Proposed Prices

Comments:

1. The SF 33/completed Section B of Volume I represents the offeror's proposed price, its offer, not those on the Template.

2. The proposed unit prices shall be carried out to two decimal places ($xx.xx).

3. The offeror's total price shall be calculated as follows: proposed unit price multiplied by the CLIN quantity.

4. The resulting proposed total prices shall be linked to the "Total Proposed Prices" worksheet.

5. The unit and total prices on the Section B worksheet shall match those on the offeror's Completed Section B in Volume I.

CLIN/SLIN	Description	Contract Type	U/M	QTY	Unit Price	Total Price
0001	Transition-In	FFP	LO	1		$ - 0
0002	Reports, Contract Data Requirements List (DD Form 1423)					NSP
	Total Base Period Price					$ - 0
CLIN/SLIN	Description	Contract Type	U/M	QTY	Unit Price	Total Price
1001	Single Enrollment Premium	FFP	EA	3,150,000.00		$ - 0
100101	Junior Enlisted (E1-E4)	FFP	EA
100102	E5 and above ranks	FFP	EA
1002	Family Enrollment Premium	FFP	EA	5,592,000.00		$ - 0
100201	Junior Enlisted (E1-E4)	FFP	EA
100202	E5 and above ranks	FFP	EA
1003	Survivor Benefit-Single Enrollment Premium	FFP	EA	44,100.00		$ - 0
1004	Survivor Benefit-Family Enrollment Premium	FFP	EA	46,620.00		$ - 0
1005	Reimbursement for Cost in Excess of Allowable Charges for OCONUS Claims	CR	LO	1	$ 694,140.00	$ 694,140.00
1006	Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS Claims	CR	LO	1	$ 3,564,988.00	$ 3,564,988.00
1007	NIST and Physical & Personnel Security	FFP	MO	12		$ - 0
1008	Incentives		LO	1	$ 1,775,000.00	$ 1,775,000.00
1009	Reports, Contract Data Requirements List (DD Form 1423)					NSP
1010	Transition-out	FFP	LO	1		$ - 0
	Total Ordering Period 1 Price					$ 6,034,128.00
CLIN/SLIN	Description	Contract Type	U/M	QTY	Unit Price	Total Price
2001	Single Enrollment Premium	FFP	EA	3,181,500.00		$ - 0
200101	Junior Enlisted (E1-E4)	FFP	EA
200102	E5 and above ranks	FFP	EA
2002	Family Enrollment Premium	FFP	EA	5,647,920.00		$ - 0
200201	Junior Enlisted (E1-E4)	FFP	EA
200202	E5 and above ranks	FFP	EA
2003	Survivor Benefit-Single Enrollment Premium	FFP	EA	44,541.00		$ - 0
2004	Survivor Benefit-Family Enrollment Premium	FFP	EA	47,086.20		$ - 0
2005	Reimbursement for Cost in Excess of Allowable Charges for OCONUS Claims	CR	LO	1	$ 701,081.40	$ 701,081.40
2006	Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS Claims	CR	LO	1	$ 3,600,637.88	$ 3,600,637.88
2007	NIST and Physical & Personnel Security	FFP	MO	12		$ - 0
2008	Incentives		LO	1	$ 1,775,000.00	$ 1,775,000.00
2009	Reports, Contract Data Requirements List (DD Form 1423)					NSP
2010	Transition-out	FFP	LO	1		$ - 0
	Total Ordering Period 2 Price					$ 6,076,719.28
CLIN/SLIN	Description	Contract Type	U/M	QTY	Unit Price	Total Price
3001	Single Enrollment Premium	FFP	EA	3,213,315.00		$ - 0
300101	Junior Enlisted (E1-E4)	FFP	EA
300102	E5 and above ranks	FFP	EA
3002	Family Enrollment Premium	FFP	EA	5,704,399.20		$ - 0
300201	Junior Enlisted (E1-E4)	FFP	EA
300202	E5 and above ranks	FFP	EA
3003	Survivor Benefit-Single Enrollment Premium	FFP	EA	44,986.41		$ - 0
3004	Survivor Benefit-Family Enrollment Premium	FFP	EA	47,557.06		$ - 0
3005	Reimbursement for Cost in Excess of Allowable Charges for OCUNUS Claims	CR	LO	1	$ 708,092.21	$ 708,092.21
3006	Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS Claims	CR	LO	1	$ 3,636,644.26	$ 3,636,644.26
3007	NIST and Physical & Personnel Security	FFP	MO	12		$ - 0
3008	Incentives		LO	1	$ 1,775,000.00	$ 1,775,000.00
3009	Reports, Contract Data Requirements List (DD Form 1423)					NSP
3010	Transition-out	FFP	LO	1		$ - 0
	Total Ordering Period 3 Price					$ 6,119,736.47
CLIN/SLIN	Description	Contract Type	U/M	QTY	Unit Price	Total Price
4001	Single Enrollment Premium	FFP	EA	3,245,448.15		$ - 0
400101	Junior Enlisted (E1-E4)	FFP	EA
400102	E5 and above ranks	FFP	EA
4002	Family Enrollment Premium	FFP	EA	5,761,443.19		$ - 0
400201	Junior Enlisted (E1-E4)	FFP	EA
400202	E5 and above ranks	FFP	EA
4003	Survivor Benefit-Single Enrollment Premium	FFP	EA	45,436.27		$ - 0
4004	Survivor Benefit-Family Enrollment Premium	FFP	EA	48,032.63		$ - 0
4005	Reimbursement for Cost in Excess of Allowable Charges for OCONUS Claims	CR	LO	1	$ 715,173.14	$ 715,173.14
4006	Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS Claims	CR	LO	1	$ 3,673,010.70	$ 3,673,010.70
4007	NIST and Physical & Personnel Security	FFP	MO	12		$ - 0
4008	Incentives		LO	1	$ 1,775,000.00	$ 1,775,000.00
4009	Reports, Contract Data Requirements List (DD Form 1423)					NSP
4010	Transition-out	FFP	LO	1		$ - 0
	Total Ordering Period 4 Price					$ 6,163,183.84
CLIN/SLIN	Description	Contract Type	U/M	QTY	Unit Price	Total Price
5001	Single Enrollment Premium	FFP	EA	3,277,902.63		$ - 0
500101	Junior Enlisted (E1-E4)	FFP	EA
500102	E5 and above ranks	FFP	EA
5002	Family Enrollment Premium	FFP	EA	5,819,057.62		$ - 0
500201	Junior Enlisted (E1-E4)	FFP	EA
500202	E5 and above ranks	FFP	EA
5003	Survivor Benefit-Single Enrollment Premium	FFP	EA	45,890.64		$ - 0
5004	Survivor Benefit-Family Enrollment Premium	FFP	EA	48,512.96		$ - 0
5005	Reimbursement for Cost in Excess of Allowable Charges for OCONUS Claims	CR	LO	1	$ 722,324.87	$ 722,324.87
5006	Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS Claims	CR	LO	1	$ 3,709,740.81	$ 3,709,740.81
5007	NIST and Physical & Personnel Security	FFP	MO	12		$ - 0
5008	Incentives		LO	1	$ 1,775,000.00	$ 1,775,000.00
5009	Reports, Contract Data Requirements List (DD Form 1423)					NSP
5010	Transition-out	FFP	LO	1		$ - 0
	Total Ordering Period 5 Price					$ 6,207,065.68
CLIN/SLIN	Description	Contract Type	U/M	QTY	Unit Price	Total Price
6001	Single Enrollment Premium	FFP	EA	1,655,340.83		$ - 0
600101	Junior Enlisted (E1-E4)	FFP	EA
600102	E5 and above ranks	FFP	EA
6002	Family Enrollment Premium	FFP	EA	2,938,624.10		$ - 0
600201	Junior Enlisted (E1-E4)	FFP	EA
600202	E5 and above ranks	FFP	EA
6003	Survivor Benefit-Single Enrollment Premium	FFP	EA	23,174.77		$ - 0
6004	Survivor Benefit-Family Enrollment Premium	FFP	EA	24,499.04		$ - 0
6005	Reimbursement for Cost in Excess of Allowable Charges for OCONUS Claims	CR	LO	1	$ 364,774.06	$ 364,774.06
6006	Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS Claims	CR	LO	1	$ 1,873,419.11	$ 1,873,419.11
6007	NIST and Physical & Personnel Security	FFP	MO	6		$ - 0
6008	Incentives		LO	1	$ 887,500.00	$ 887,500.00
6009	Reports, Contract Data Requirements List (DD Form 1423)					NSP
6010	Transition-out	FFP	LO	1		$ - 0
	Total FAR 52.217-8, Option to Extend Services 6 months Price					$ 3,125,693.17
	Phase-Out CLINs - The Government intends to only exercise one phase out CLIN in the performance of this contract.
CLIN/SLIN	Description	Contract Type	U/M	QTY	Unit Price	Total Price
7001	Residual Services Phase-Out - Ordering Period 1	FFP	LO	1		$ - 0
7002	Residual Services Phase-Out - Ordering Period 2	FFP	LO	1		$ - 0
7003	Residual Services Phase-Out - Ordering Period 3	FFP	LO	1		$ - 0
7004	Residual Services Phase-Out - Ordering Period 4	FFP	LO	1		$ - 0
7005	Residual Services Phase-Out - Ordering Period 5	FFP	LO	1		$ - 0
	Total Phase-Out					$ - 0
	Summary
						Total Price
	Total Base Period Price					$ - 0
	Total Ordering Period 1 Price					$ 6,034,128.00
	Total Ordering Period 2 Price					$ 6,076,719.28
	Total Ordering Period 3 Price					$ 6,119,736.47
	Total Ordering Period 4 Price					$ 6,163,183.84
	Total Ordering Period 5 Price					$ 6,207,065.68
	Total Contract, without Transition-Out and Residual Phase-Out					$ 30,600,833.27
	Transition-Out and Residual Phase-Out					$ - 0
	Total Contract, with Transition-Out and Residual Phase-Out					$ 30,600,833.27
	6-month Extension - 50% of Ordering Period 5, not including Transition-Out					$ 3,125,693.17
	Total Evaluated Price (TEP)					$ 33,726,526.43

Total Proposed Prices

Solicitation Number: HT9402-22-R0001

Service: TRICARE Dental Plan 6

Offeror:

Price Evaluation Template

Total Proposed Prices

		Base	Ordering Period 1	Ordering Period 2	Ordering Period 3	Ordering Period 4	Ordering Period 5	Option to Extend Services	Grand
CLIN	Description	Total Price	Total Price	Total Price	Total Price	Total Price	Total Price	Total Price	Total Price
0001	Transition-In	$ - 0							$ - 0
0002	Reports, Contract Data Requirements List (DD Form 1423)	NSP
x001	Single Enrollment Premium		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
x002	Family Enrollment Premium		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
x003	Survivor Benefit-Single Enrollment Premium		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
x004	Survivor Benefit-Family Enrollment Premium		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
x005	Reimbursement for Cost in Excess of Allowable Charges for OCONUS Claims		$ 694,140	$ 701,081	$ 708,092	$ 715,173	$ 722,325	$ 364,774	$ 3,905,586
x006	Reimbursement for Cost Shares and Additional Allowable Charges for Orthodontic Costs Charge for OCONUS Claims		$ 3,564,988	$ 3,600,638	$ 3,636,644	$ 3,673,011	$ 3,709,741	$ 1,873,419	$ 20,058,441
x007	NIST and Physical & Personnel Security		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
x008	Incentives		$ 1,775,000	$ 1,775,000	$ 1,775,000	$ 1,775,000	$ 1,775,000	$ 887,500	$ 9,762,500
x009	Reports, Contract Data Requirements List (DD Form 1423)		NSP	NSP	NSP	NSP	NSP	NSP
x0010	Transition-out		$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
	Total Option/Contract, without Transition-Out	$ - 0	$ 6,034,128.00	$ 6,076,719.28	$ 6,119,736.47	$ 6,163,183.84	$ 6,207,065.68	$ 3,125,693.17	$ 30,600,833

Transition-Out $ - 0

Total Contract, with Transition-Out $ 30,600,833

6-month Extension - 50% of Ordering Period 5, not including Transition-Out	$ 3,125,693
Total Evaluated Price (TEP)	$ 33,726,526

NOTE:

1. The CLIN/SLIN total prices for the above worksheet are derived from/linked to the worksheets in the "Section B" tab.

2. CDRLS are not separately priced (NSP). However, the offeror shall provide an estimated price for each CDRL in its proposal for Government budgetary purposes. See CDRL worksheet tab.

CDRLs

Solicitation Number: HT9402-22-R0001

Service: TRICARE Dental Plan 6

Offeror:

Price Evaluation Template

Contract Data Requirements List (CDRLs)

Estimated Prices for each CDRL

Comments:
1. In accordance with DFARS 215.470, Estimated Data Prices, DoD requires estimates of the prices of data in order
to evaluate the cost to the Government in terms of their management, product, or engineering value.
2. The CDRLs are Not Separately Priced (NSP) in the Section B worksheet or the Completed Section B of Volume I.
3. The Offeror shall provide price/cost estimates for each CDRL for Government budgetary use.
		Transition-In	Ordering Period 1	Ordering Period 2	Ordering Period 3	Ordering Period 4	Ordering Period 5	Option to Extend Services
CDRL Number	CDRL Title	Price	Price	Price	Price	Price	Price	Price
A010	Proposed FOIA Releasable Contract	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
A020	Risk Assessment Letter of Assurance	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
A030	Disaster Recovery Test Results Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
A040	Fraud Detection and Prevention Strategy and Int Procedures	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
AP010	Beneficiary and Provider Education Plan	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
AP020	Continuity of Ops Plan	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
AP030	QCP Plan	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
AP040	Continuation of Essential Contractor Services Plan	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
AP050	System Security Plan and Associated Plans of Action for a Contractor's Internal Unclassified Information System	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
M010	Management Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
M020	Provider Network Access Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
M030	OCONUS Payment Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
M040	HIPAA Privacy Complaint Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
M050	Worldwide Incurred-Paid Claims Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
M060	MDR Data Claims and Provider Files	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
M070	Enrollment and Fee Reconciliation Analysis Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
M080	Employee Access to DOD IS Networks Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
M090	Transition-Out and Residual Services Status Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Q010	QCP Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Q020	Fraud and Abuse Summary Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
Q030	Enrollment Activity Summary Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R010	Breach Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R020	Identification of Systems of Record Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R030	Transition-In IMP and IMS	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R040	Transition-Out and Residual Services Plan	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R050	National Disaster Action Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R060	Threats Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R070	DSMO Summary Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R080	Ad Hoc Management Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R090	Standard Operating Procedures (Desk Procedures)	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R100	Consolidated TDP Historical Data File	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R110	MOU with DHA Communications	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R120	Appeals Processing Guidelines, Desk Instructions and Reference Materials	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R130	Declaration of Transfer and Destruction of Records	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R140	Random Sample Audit Worksheet	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R150	Fraud Abuse Patient Harm - Intl Notice Checklist	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R160	DHA MTF Fraud and Abuse Referral Cover Sheet	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R170	B2B Gateway Questionnaire	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
R180	CLIN Price Structure	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
S010	Utilization Report by Uniformed Services AD Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
S020	Utilization Report by Uniformed Services NGR Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
S030	Utilization CONUS OCONUS Frequency Dollar Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
S040	Utilization CONUS OCONUS Denied Services Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
S050	Survivor Covered Lives and Utilization Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0
W010	Transition-In Status Report	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0	$ - 0

File details come from the government source that posted it. Updated Oct 26, 2022.