S02_Issued_combined Synopsis__36C10X22Q0041_12-21-2021.docx

SUBJECT*

Camp Lejeune Family Member Program Pharmacy Benefits Manager (PBM) Services (VA-22-00004826)

GENERAL INFORMATION

Department of Veterans Affairs

5202 Presidents Court, Suite 103 Frederick MD 21703

POINT OF CONTACT*

Contract Specialist Cedric Jackson cedric.jackson@va.gov

PLACE OF PERFORMANCE

ADDRESS

POSTAL CODE

COUNTRY

ADDITIONAL INFORMATION

AGENCY CONTACT’S EMAIL ADDRESS

EMAIL DESCRIPTION

DESCRIPTION

This is a combined synopsis/solicitation for commercial items prepared in accordance with the format in Subpart 12.6, as supplemented with additional information included in this notice. This announcement constitutes the only solicitation; quotes are being requested and a separate written solicitation will not be issued. The Solicitation 36C10X22Q0041 issued as a Request for Quote (RFQ). This solicitation is being conducted under FAR Part 13 Simplified Acquisition Procedures (SAP). This solicitation document and incorporated provisions and clauses are those in effect through Federal Acquisition Circular 2022-01, and Acquisition Policy Flash 22-08 effective December 6, 2021. The NAICS Code is 524114 – Medical service plans without providing health care services. The Product Service Code (PSC) is Support- Management: Data Collection. The Small Business size standard is 41.5 Million. The Government will award a single award contract resulting from this solicitation.

Quote Due Date: 1/06/2022 at 10:00 AM ET Questions Due Date: 12/27/2021 at Noon ET The provision at FAR 52.212-1, Instructions to Offerors -- Commercial, applies to this acquisition and an addendum is below.

The clause at FAR 52.212-4, Contract Terms and Conditions -- Commercial Items, applies to this acquisition and an addendum is below.

Combined Synopsis/Solicitation Notice

36C10X22Q0041

See below for further requirements and solicitation details.

Combined Synopsis/Solicitation Notice

PAGE 1 OF

1. REQUISITION NO.

2. CONTRACT NO.

3. AWARD/EFFECTIVE DATE

4. ORDER NO.

5. SOLICITATION NUMBER

6. SOLICITATION ISSUE DATE

a. NAME

b. TELEPHONE NO. (No Collect Calls)

8. OFFER DUE DATE/LOCAL

TIME

9. ISSUED BY

CODE

10. THIS ACQUISITION IS

UNRESTRICTED OR

SET ASIDE:

% FOR:

SMALL BUSINESS

HUBZONE SMALL

BUSINESS

SERVICE-DISABLED

VETERAN-OWNED

SMALL BUSINESS

WOMEN-OWNED SMALL BUSINESS

(WOSB) ELIGIBLE UNDER THE WOMEN-OWNED

SMALL BUSINESS PROGRAM

EDWOSB

8(A)

NAICS:

SIZE STANDARD:

11. DELIVERY FOR FOB DESTINA-

TION UNLESS BLOCK IS

MARKED

SEE SCHEDULE

12. DISCOUNT TERMS

13a. THIS CONTRACT IS A

RATED ORDER UNDER

DPAS (15 CFR 700)

13b. RATING

14. METHOD OF SOLICITATION

RFQ

IFB

RFP

15. DELIVER TO

CODE

16. ADMINISTERED BY

CODE

17a. CONTRACTOR/OFFEROR

CODE

FACILITY CODE

18a. PAYMENT WILL BE MADE BY

CODE

TELEPHONE NO.

DUNS:

DUNS+4:

PHONE:

FAX:

17b. CHECK IF REMITTANCE IS DIFFERENT AND PUT SUCH ADDRESS IN OFFER 18b. SUBMIT INVOICES TO ADDRESS SHOWN IN BLOCK 18a UNLESS BLOCK BELOW IS CHECKED

SEE ADDENDUM

19.

20.

21.

22.

23.

24.

ITEM NO.

SCHEDULE OF SUPPLIES/SERVICES

QUANTITY

UNIT

UNIT PRICE

AMOUNT

(Use Reverse and/or Attach Additional Sheets as Necessary)

25. ACCOUNTING AND APPROPRIATION DATA

26. TOTAL AWARD AMOUNT (For Govt. Use Only) 27a. SOLICITATION INCORPORATES BY REFERENCE FAR 52.212-1, 52.212-4. FAR 52.212-3 AND 52.212-5 ARE ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED.

27b. CONTRACT/PURCHASE ORDER INCORPORATES BY REFERENCE FAR 52.212-4. FAR 52.212-5 IS ATTACHED. ADDENDA

ARE

ARE NOT ATTACHED

28. CONTRACTOR IS REQUIRED TO SIGN THIS DOCUMENT AND RETURN _______________

29. AWARD OF CONTRACT: REF. ___________________________________ OFFER

COPIES TO ISSUING OFFICE. CONTRACTOR AGREES TO FURNISH AND

DATED ________________________________. YOUR OFFER ON SOLICITATION

DELIVER ALL ITEMS SET FORTH OR OTHERWISE IDENTIFIED ABOVE AND ON ANY

(BLOCK 5), INCLUDING ANY ADDITIONS OR CHANGES WHICH ARE

ADDITIONAL SHEETS SUBJECT TO THE TERMS AND CONDITIONS SPECIFIED

SET FORTH HEREIN IS ACCEPTED AS TO ITEMS:

30a. SIGNATURE OF OFFEROR/CONTRACTOR 31a. UNITED STATES OF AMERICA (SIGNATURE OF CONTRACTING OFFICER) 30b. NAME AND TITLE OF SIGNER (TYPE OR PRINT) 30c. DATE SIGNED 31b. NAME OF CONTRACTING OFFICER (TYPE OR PRINT) 31c. DATE SIGNED

AUTHORIZED FOR LOCAL REPRODUCTION

(REV. 2/2012)

PREVIOUS EDITION IS NOT USABLE

Prescribed by GSA - FAR (48 CFR) 53.212

7. FOR SOLICITATION

INFORMATION CALL:

STANDARD FORM 1449

OFFEROR TO COMPLETE BLOCKS 12, 17, 23, 24, & 30

SOLICITATION/CONTRACT/ORDER FOR COMMERCIAL ITEMS

36C10X22Q0041 12-2 -2021 Cedric Jackson

(240) 215-1651 01-06-202 10:00am

EST

36C10X Strategic Acquisition Center - Frederick Department of Veterans Affairs 5202 Presidents Court, Suite 103 Frederick MD 21703 X X 524114 $41.5 Million N/A X Pharmacy Network throughout the fifty United States, DC, Puerto Rico, Guam Northern Mariana Islands, U.S Virgin Islands, American Samoa, and the Minor outlying Islands.

36C10X Strategic Acquisition Center - Frederick Department of Veterans Affairs 5202 Presidents Court, Suite 103 Frederick MD 21703

VAFSC

U.S. Department of Veterans Affairs Financial Services Center

PO BOX 149971

(see Section B.3 invoicing/payment) Austin TX 78714-8917 1-(877)-489-6135 See CONTINUATION Page Department of Veterans (VA) has a requirement to establish a Pharmacy Benefit Management Services in support of the VA Administered Camp Lejeune Family member Program (CLFMP) Questions are due by Monday, December 27, 2021 at Noon ET

TINS:_____________________

DUNS:___________________

CAGE:____________________

See CONTINUATION Page X X X X Jennifer Swift Contracting Officer Page 1 of Page 1 of Table of Contents

SECTION B - CONTINUATION OF SF 1449 BLOCKS

B.1 CONTRACT ADMINISTRATION DATA

1. Contract Administration: All contract administration matters will be handled by the following individuals:

a. CONTRACTOR:

b. GOVERNMENT: Contracting Officer 36C10X Strategic Acquisition Center - Frederick Department of Veterans Affairs 5202 Presidents Court, Suite 103 Frederick MD 21703

2. CONTRACTOR REMITTANCE ADDRESS: All payments by the Government to the contractor will be made in accordance with:

3. INVOICES: Invoices shall be submitted in arrears:

4. GOVERNMENT INVOICE ADDRESS: All Invoices from the contractor shall be submitted electronically in accordance with VAAR Clause 852.232-72 Electronic Submission of Payment Requests.

U.S. Department of Veterans Affairs Financial Services Center

PO BOX 149971

(see Section B.3 invoicing/payment) Austin TX 78714-8917

ACKNOWLEDGMENT OF AMENDMENTS: The offeror acknowledges receipt of amendments to the Solicitation numbered and dated as follows:

B.2 PERFORMANCE WORK STATEMENT

1.0 Background

The Department of Veterans Affairs (VA), Financial Services Center (FSC), requires the ability to process pharmacy claims transactions for the Camp Lejeune Family Member Program (CLFMP) currently administered by VA. The programs covered under CLFMP includes specific conditions as described under Public Law 112-154 dated August 6, 2012, to family members of Veterans stationed at Camp Lejeune from August 1, 1953 to December 31, 1987. The FSC intends to adjudicate pharmacy claims transactions via Health Insurance Portability and Accountability Act (HIPAA) Compliant Electronic Data Interchange (EDI). The FSC intends to utilize the expertise of a Pharmacy Benefit Manager (PBM) who will coordinate with an extensive network of retail and specialty pharmacies. The PBM will administer pharmacy claim transactions throughout the fifty United States, District of Columbia, Puerto Rico, Guam, U.S. Virgin Islands, Northern Mariana Islands, American Samoa, and Minor Outlying Islands. They are primarily responsible for processing and paying prescription drug claims. They also are responsible for developing and maintaining the formulary, contracting with pharmacies, and negotiating discounts and rebates with drug manufacturers.

2.0 The anticipated Period of Performance is one (1) twelve (12) month base period and four (4) 12-month options. VA reserves the sole authority to exercise any options presented within this Performance Work Statement and no options shall be initiated by the Contractor without official written notification from the Contracting Officer.

A. Unless otherwise stated within the PWS, Hours of Operation and Information Services shall be provided between the hours of 8:00 AM to 4:30 PM (EST), excluding weekends and Federal Holidays. This includes time for the virtual session to open 15 minutes prior to start time.

B. Any work with the Government staff shall not take place on Federal holidays or weekends unless directed by the Contracting Officer (CO).

C. There are eleven (11) Federal holidays set by law (U.S.C Title 5 Section 6103) that VA follows.

1. Under current definitions, four are set by date:

1. If any of the above falls on a Saturday, then Friday shall be observed as a holiday. Similarly, if one falls on a Sunday, the Monday shall be observed as a holiday.

D. The other seven holidays are set by a day of the week and month:

2.1 Place of Performance

The Contractor shall establish and maintain a pharmacy network throughout the fifty United States, the District of Columbia, Puerto Rico, Guam, Northern Mariana Islands, U.S. Virgin Islands, American Samoa, and the Minor Outlying Islands.

3.0 Scope of Work

The FSC requires a Contractor to provide PBM services to coordinate with pharmacies throughout the fifty United States, District of Columbia, Puerto Rico, Guam, U.S. Virgin Islands, Northern Mariana Islands, American Samoa, and Minor Outlying Islands, for covered conditions as defined under Public Law 112-154. The Contractor and its network pharmacy providers agree to abide by the rules, regulations and procedures governing the various programs administered by the FSC and in accordance with applicable Federal and State laws. The Contractor shall be certified by the Utilization Review Accreditation Commission (URAC) prior to the contract effective date.

The CLFMP is VA’s health benefits program developed for family members of Veterans who resided at Camp Lejeune, North Carolina, for no fewer than 30 days during the period of August 1, 1953 to December 31, 1987 and are diagnosed with one of the 15 conditions identified in Public Law 112-154. Estimated prescription activity based upon program estimates is up to 30,000 prescriptions per year. Many CLFMP beneficiaries are covered by Other Health Insurance (OHI). Those beneficiaries who have OHI, this program will pay for pharmacy claims as the payer of last resort.

4.0 Requirements / Specific Tasks

4.1 Contractor responsibilities:

a. The Contractor shall provide claims processing via a network of pharmacies in the most cost-efficient method to the government by achieving cost savings, in accordance with the highest standards of retail pharmacy practice.

b. The Contractor shall receive pharmacy claims data in the Health Insurance Portability and Accountability Act (HIPAA) designated electronic format.

c. The Contractor shall provide a comprehensive pharmacy network to all the CLFMP beneficiaries living in the fifty United States, the District of Columbia, Puerto Rico, Guam, U.S. Virgin Islands, Northern Mariana Islands, American Samoa, and the Minor Outlying Islands.

d. The Contractor shall provide a conduit for on-line coordination of benefits from other primary payers, such as Medicare Part D, to the FSC.

e. The Contractor shall provide the FSC with NCPDP (National Council for Prescription Drug Programs) compliant batch files containing electronically received claims that were submitted for processing on a regularly scheduled basis.

f. The Contractor shall provide detailed reports of pharmacy claims history to the FSC.

g. The Contractor shall establish and maintain weekly or as needed communication between the FSC, and other appropriate parties by phone, email, or face to face meetings.

h. The Contractor shall provide on an annual basis a Statement on Standards for Attestation Engagements (SSAE) 16 audit report.

4.2 Contractor program requirements:

a. The Contractor shall provide all labor, materials, equipment, transportation, ancillary products and services, to include the supervision and management necessary to complete the requirements of this Performance Work Statement (PWS) in accordance with the highest level of quality standards and aligned with accepted industry best practices through URAC (Utilization Review Accreditation Commission) defined standards and accreditation.

b. Under no circumstances and in no way will the Contractor act as a representative of the FSC.

c. Claims accepted at the point of sale by the Contractor’s network providers do not guarantee payment.

d. The FSC performs the final adjudication and determines payment for all eligible claims, per the Scope outlined in Section 3.0 of this PWS. The Contractor is not authorized or responsible for any adjudication of claims or payment of rejected claims. The Contractor shall provide pharmacy benefits to those claimants on the eligibility file provided by the FSC. If the Contractor provides benefits to a claimant who is not on the eligibility file at the time of the claim, then the Contractor shall be responsible for the costs without exception.

e. It is expressly agreed and understood that the pharmaceutical services rendered by pharmacies represented by the Contractor are rendered in their capacity as autonomous pharmacies. The FSC retains no control or supervision over the professional aspects of the pharmaceutical services of these pharmacies. The PBM is responsible for maintaining the appropriate, ethical relationships with the pharmacies to ensure proper and expeditious claims processing for all beneficiaries covered under the requirements of this PWS (Section 3.0).

f. The Contractor shall accept from the FSC at minimum one daily file which will include the Eligibility File. The daily Eligibility File contains eligible beneficiaries within CLFMP and will be loaded into the Contractor’s beneficiary eligibility database no later than 6:00AM (EST) when available from the Government by 2:00 AM EST. The Contractor shall provide pharmacy benefits to those claimants on the eligibility file provided by the FSC. If the Contractor provides benefits to a claimant who is not on the eligibility file at the time of the claim, then the Contractor shall be responsible for the costs.

g. The Contractor shall submit four separate files daily, to include but not limited to the following: Coordination of Benefits (COB) Claims file, COB Reversal file, Standard Retail Benefit Claims File and Standard Retail Benefit Reversal File. Files will be submitted to FSC by 11:00AM EST daily, to include Saturday and Sunday.

h. All Contractor programs have a unique identifier for each person on the eligibility file that is transmitted daily. Contractor beneficiaries have a unique program authorization card, with name and ID number (printed as “Beneficiary SSN” on the front) issued from the FSC.

i. The Contractor shall provide a Pharmacy ID card to identified eligible beneficiaries from the supplied FSC eligibility file for use within the pharmacy network. The Contractor supplied Pharmacy ID card will comply with National Council for Prescription Drug Programs (NCPDP) standards. The Contractor shall provide all Pharmacy ID cards to beneficiaries within seven days of receipt of request (includes new cards, lost card, and eligibility status change).

j. The use of any FSC logos and all marketing information provided by the Contractor to Network Pharmacies or FSC beneficiaries must be approved by the FSC prior to distribution, without exception.

k. The Contractor and/or the network provider shall not assess any fees or charges to FSC for testing; this includes all implementation and/or transmission of claims for testing purposes. All data transmission expenses associated with submitting and receiving test data under this agreement shall be borne by the Contractor and/or its pharmacy providers. The FSC will cover any equipment or software costs that the FSC may require for new initiatives requested by the FSC or required by regulation in order for the FSC to process claims from the Contractor.

l. The Contractor shall ensure, by way of on-line real-time adjudication edits that all claims submitted for CLFMP, do not include any excluded prescription drugs, medical supplies or devices. The submission of an electronic claim by the Contractor is a claim for payment and intentional misrepresentation or falsification of any record or other information essential to that claim is subject to prosecution under federal criminal and civil laws and, upon conviction, may result in fines and/or imprisonment.

m. The Contractor and pharmacy provider will inquire of the beneficiary about Other Health Insurance (OHI) status and incorporate OHI information into their point-of-sale adjudication process in accordance with program requirements. Identifiers exist on the FSC eligibility file that denotes the CLFMP beneficiary health plan and OHI coverage. The FSC will reject claims where there are indications that the beneficiary has primary OHI. If this is identified after the fact, the PBM should issue the FSC a credit.

n. The Contractor shall have the necessary personnel to authorize overrides to rejected claims from network pharmacies. The Contractor is given specific authority to override edits in certain instances for vacation supplies, lost medications and other instances as determined by the FSC and established at contract award.

o. Claims for medical supplies (non-drug items), which have National Drug Codes (NDC), may be submitted by the network pharmacies to the Contractor using NCPDP telecommunication standards as established by HIPAA rules. FSC will provide an official list of covered items upon contract award.

p. The VA FSC will reimburse the contractor for Over-the-Counter (OTC) medicines (prescription required).

q. Contractor shall assign a clinical pharmacist to oversee all clinical support services.

4.3 Clinical

4.3.1 Condition

a. The Government shall update and maintain the condition specific formulary.

b. Formulary additions recommended by the contractor shall be adopted, edited and maintained by the Government. Concurrence from the Government will be received prior to updating the formulary.

c. The contractor shall have 5 business days notification.

d. An updated version of the condition specific formulary will be posted to the Government CLFMP website quarterly (only if any changes have been made). The contractor shall have a 7-to-10-day notice before the formulary is posted.

e. Rejections (medicines not on the condition specific formulary will be forwarded to the Government clinical team for review and approval. Denials may refer that additional medical documentation is necessary or an updated Treating Physician Report (TPR) is needed. The contractor may advise the Family Member of the additional/revised documentation required.

4.3.2 Open formulary

a. Updates to the open formulary shall be edited, maintained and communicated by the contractor to the Government. Concurrence from the Government will be received prior to updating the formulary.

4.3.3 Active vs Remissive

a. The Government shall pay (not through the order) for any open formulary medications prescribed to a CLFMP member in an active state of cancer. The active state is determined by the Government from medical documentation received and the Treating Physician Report.

b. The Government shall pay for ONLY those medications prescribed for a CLFMP member published on the condition specific formulary for eligible conditions in a remissive state.

4.3.4 The Government shall only cover compounds with prior approval.

4.3.5 Rejections for non-formulary medications will be forwarded to the Government clinical team for review and approval within 4 hours during normal business hours, and within one business day during all instances.

4.4 Specific Requirements Pharmacy Network Access:

a. The contractor shall create and maintain a pharmacy network sufficient to meet the following minimum beneficiary access standards on an overall basis:

· Urban: a pharmacy within two-ten miles estimated driving distance of 90% of the beneficiaries;

· Suburban: a pharmacy within eleven- twenty miles estimated driving distance of 90% of the beneficiaries;

· Rural: a pharmacy within twenty-one to fifty miles estimated driving distance of 90% of the beneficiaries.

b. The Contractor shall ensure that the number of pharmacies included in its network does not decrease by more than 10% of the total number of pharmacies originally proposed for its network.

4.4.1 Pharmacy Network Services:

a. The Contractor shall establish and maintain a pharmacy network throughout the fifty United States, the District of Columbia, Puerto Rico, Guam, Northern Mariana Islands, U.S. Virgin Islands, American Samoa, and the Minor Outlying Islands.

b. All network pharmacies must be fully licensed and certified in accordance with applicable Federal and State laws and credentialed according to the Contractor’s criteria. This information must be made available to the FSC upon request.

c. The Contractor shall provide technical assistance to network pharmacies through the Contractor’s pharmacy help desk. The Contractor shall coordinate with the FSC for those inquiries that require FSC input.

d. The Contractor shall require network pharmacies to maintain a process to document the receipt of medication by a CLFMP beneficiary or the beneficiary’s authorized agent and meet HIPAA requirements.

e. The Contractor shall ensure that network pharmacies collect beneficiary cost share amounts as returned on the paid claim’s response. The Contractor shall provide written instructions to each participating pharmacy provider that includes an explanation of each of the FSC programs, a copy of the sample Pharmacy ID Card and specific guidelines regarding pharmacy benefits and the terms of this contract.

f. The Contractor shall review, update and disseminate these written instructions and/or provider agreement addendum any time there are substantive changes to FSC program requirements or the contract. Any provider manual and all updates to the written instructions require approval by the FSC prior to distribution.

g. The FSC requires the PBM to support the National Council for Prescription Drug Programs (NCPDP) telecommunication standard for transmission of electronic prescribing functionality throughout the network of retail and specialty pharmacies as a means to improve the safety and accuracy of the prescribing process. The PBM must be able to adjudicate claims utilizing electronic prescribing capabilities in the allowable NCPDP SCRIPT standard for the secure, electronic transmission of prescriptions and prescription related information. These capabilities must allow an eligible prescriber to select medications, print prescriptions, transmit prescriptions electronically, and receive safety alerts. These alerts must include automated prompts that offer information on the drug being prescribed and warn the prescriber of possible undesirable or unsafe situations regarding current and profile medications, such as potential drug-drug interactions, duplicate therapies, and dosing warnings/cautions.

4.4.2 Claims Submission to the Contractor by Network Pharmacy Provider:

a. The Contractor shall ensure, at its own expense, that electronic claims are submitted on- line, in real time, utilizing HIPAA designated standards.

b. The Contractor shall ensure that network pharmacies submit any claims for processing within two years of the date of service. Claims submitted after the two-year filing deadline will be denied by the FSC.

c. The Contractor shall accept and process all electronic claims received from network pharmacies for pharmaceuticals and supplies furnished in the fifty United States, the District of Columbia, Puerto Rico, Guam, Northern Mariana Islands, U.S. Virgin Islands, American Samoa, and the Minor Outlying Islands.

d. The Contractor shall ensure that reversals from network pharmacies are sent timely. FSC expects reversals be completed within a 7-day cycle; however, all prescriptions not received by eligible members must be reversed within 45 days of processing.

e. The Contractor shall ensure that each claim passes administrative and plan edits established by FSC policy. Modification to the claim edits or other electronic media claim procedures must be submitted in writing to the Contractor by the FSC. The Contractor will be provided time to make any necessary system changes to accommodate such modifications; however, since the time required is dependent on the complexity of any change, the Contractor and the FSC will negotiate and agree in writing to reasonable timelines prior to each change.

f. The contractor shall ensure, on-line real-time adjudication edits that all claims submitted for CLFMP do not include any excluded prescription drugs, medical supplies, or devices.

g. Daily, the Contractor shall submit at least four separate files to include but not limited to the following: Standard Business Billing and Reversal, Standard Retail Benefit Claims file and Standard Retail Benefit Reversal file. Files will be submitted on a daily basis by 11:00AM EST. The Contractor will be advised of all discrepancies by the FSC via a primary proprietary response file.

h. Paid claim (billing) files will be submitted daily, in batch, to the FSC with a minimum 7-day lag to allow for a majority of claim reversals to be processed by the Contractor prior to transmission and processing at the FSC.

i. The Contractor shall provide medical documentation from the medical provider/prescriber for some medications prior to payment of the claim.

j. The FSC will apply validity and consistency edits to all submissions from the Contractor. The FSC will accept all valid claims which meet such edit requirements and return errant submissions for correction. The Contractor shall research and correct any and all discrepant claim submissions. Claims rejected for compliance prior to the FSC’s adjudication shall be corrected by the Contractor and resubmitted electronically as a new claim. (If the Contractor receives the claim on an 835 or a secondary status report, the claim has passed through the FSC’s adjudication system.)

k. When the time frames for transmission of claims by the Contractor cannot be met, the appropriate FSC contact shall be notified by the Contractor within 2 hours of scheduled transmission by phone and e-mail of the failure to meet the time frame, reason(s) why, and estimated time to resumption of transmissions.

4.4.3 Claim Reimbursements:

a. Claim reimbursements for network claims will be made to the Contractor by the Government via Electronic Funds Transfer (EFT) from the U.S. Treasury daily on claims that have been determined to meet all criteria for reimbursement by the FSC. The Contractor, on behalf of pharmacy providers, will accept consolidated payments for all reimbursements to the same corporate tax identification number. An 835 file (ASC X12 5010 or current version) or a secondary response file with remittance information will be returned to the Contractor.

b. The allowable amounts for network claims submitted to the FSC will be based on the pricing proposal and discounts submitted to the FSC.

4.4.4 Claims Processing Standards between the Pharmacy and the Contractor

a. Ninety-eight percent (98%) of electronic claims will be processed to completion within five (5) seconds of electronic submittal of receipt of files from the pharmacy, measured on a monthly basis. By the 7TH day of each month, the Contractor shall provide electronic reports to the FSC detailing processing times for the previous month.

b. Scheduled downtime from processing of claims must not exceed eight hours during any month. The Contractor shall provide a schedule of planned outages. Planned outages must be scheduled after Midnight EST and systems must be operational by 6:00 AM EST. By the 7TH day of each month, the Contractor will provide an electronic report detailing actual outages.

c. In the event that an unscheduled outage occurs, the Contractor shall notify the FSC immediately and provide hourly updates of progress and estimated time for restoration of services by phone and e-mail. The Contractor shall use contact information provided by the FSC to report status/progress.

4.4.5 Claim Reversal Submission to the FSC:

a. The Contractor shall transmit one reversal batch (in NCPDP current Batch format) of an unlimited number of prescription claim records and assumes responsibility for ensuring that all reversals submitted to FSC contain complete information.

b. The Contractor shall be advised of the amount due for all accepted network reversal transactions by the FSC. Reversal files will be submitted daily.

c. The Contractor shall submit to FSC a paper check twice monthly with a data file for reconciliation purposes.

4.4.6 Beneficiary Rebates:

a. If the FSC determines a rebate is due; the FSC will initiate and ensure that the rebate is properly made within 45 days of the need becoming known. If the Contractor determines a rebate is due, the Contractor shall identify the rebate situation to the FSC prior to taking any action. The Contractor shall send an electronic written report to the FSC of all identified rebate situations on or before the 28th of every month. The FSC has the right to audit files that are relevant to the rebate situation.

4.4.7 Rebates:

a. The Government recognizes that there may be rebates (flat/access, performance and/or combination etc.) offered to the PBM for the claims processed under this requirement. The FSC will allow the Contractor to obtain manufacturer pharmaceutical rebates through the administration of this program while sharing the benefit of these rebates with the FSC. The Contractor shall propose the optimal rebate solution that provides a sharing of these rebate programs with the FSC. The sharing of these rebate programs should be offered in the form of discounts from monthly invoices submitted to the Government. Detailed supporting information for the discounts will be required. The contractor shall an electronic written report to the FSC of all rebate situations monthly, if applicable.

5.0 Beneficiary Help Desk:

a. The Contractor shall maintain a toll-free telephone number at their own expense for use by the FSC beneficiaries to assist with questions regarding the Contractor submitted claims, routine coverage questions, or to determine which providers are located near them. This toll-free number will be staffed, at a minimum, from 7:00AM to 11:00PM Eastern Standard Time (EST), Monday through Friday.

b. The Contractor may use an Automated Response Unit (ARU) to receive beneficiary calls. If calls are received by an ARU, 98% of all telephone calls will be acknowledged within 20 seconds. The first menu choice presented to the caller will allow the caller to be transferred to a Customer Service Representative. Each subsequent menu selection will be transferred and answered 98% of the time within 10 seconds of the menu selection being made. If the caller requests to speak with a customer service representative, the ARU should acknowledge the caller that their call will be addressed by the next available representative. A call log will be provided to FSC electronically reflecting customer support response times.

c. The Contractor shall ensure the necessary number and type of personnel are available during all hours of operation of the Beneficiary Help Desk to fully answer beneficiary questions. The Contractor shall provide warm transfers in the event calls must be transferred to FSC.

d. Telephone Response Standards: When a caller requests to speak with a Customer Service Representative, the connection shall be made within one minute, 98% of the time. The abandonment rate shall not exceed 2%. The blocked call rate shall not exceed 2%. The Contractor shall fully resolve (meaning the caller understands the resolution) all customer service calls 95% of the time during the initial call and 100% of the time resolution within two working days of receiving the initial call.

e. The contractor’s customer care team fielding phone calls from pharmacies, providers, and/or patients shall be staffed 100% with Certified Pharmacy Technicians with knowledge in pharmacy claims processing procedures.

6.0 Pharmacy Help Desk:

a. The Contractor shall maintain a toll-free telephone number at their own expense for use by the network pharmacies to assist with questions regarding the Contractor submitted claims or routine coverage questions. This toll-free number will be staffed, at a minimum, from 7:00AM to 11:00PM Eastern Standard Time (EST), Monday through Friday.

b. The Contractor may use an Automated Response Unit (ARU) to receive pharmacy calls. If calls are received by an ARU, 98% of all telephone calls shall be acknowledged within 20 seconds. The first menu choice presented to the caller shall allow the caller to be transferred to a Customer Service Representative. Each subsequent menu selection will be transferred and answered 98% of the time within 10 seconds of the menu selection being made. If the caller requests to speak with a customer service representative, the ARU should acknowledge the caller that their call will be addressed by the next available representative.

c. The Contractor shall ensure the necessary number and type of personnel are available during all hours of operation of the Pharmacy Help Desk to answer questions.

d. Telephone Response Standards: When a caller requests to speak with a Customer Service Representative, the connection will be made within one minute, 98% of the time. The abandonment rate will not exceed 4%. The blocked call rate will not exceed 2%.

e. The contractor’s customer care team fielding phone calls from pharmacies, providers, and/or patients shall be staffed 100% with Certified Pharmacy Technicians with knowledge in pharmacy claims processing procedures.

7.0 Internet Website:

a. The Contractor shall maintain an Internet 508 compliant website at its own expense. The website will have the ability to look up network locations by the zip code, prints a temporary ID card, and provide FSC beneficiaries with telephone or mailing contact information for the Contractor.

b. The contractor Customer Care telephone number will be provided on the front page of the web portal.

c. The contractor shall provide a prompt for City, State, and Zip Code search indicators to the pharmacy locator of the contractor CLMFP web portal.

d. The contractor shall include an indicator to identify compound pharmacies.

e. The contractor shall remove CBOCs and VAMCs pharmacies from the locator.

f. The contractor shall include the CLFMP condition formulary link.

8.0 Access to Claim Data:

a. Parties to this contract will ensure only authorized access to this data to guarantee that the electronic data interchange (EDI) messages are authentic, properly authorized and traceable. The messages will also be protected from loss, modification, or unauthorized disclosure both during transmission and storage. Health claim submissions for treatment for sickle cell anemia, Human Immunodeficiency Virus (HIV), and substance and alcohol abuse are specifically protected by 38 U.S.C. S 7332. This statute includes a penalty provision for the unauthorized use or disclosure of information. To maintain confidentiality and to preclude the filing of fraudulent claims, access to any and all claims data will be restricted to:

1) The designated/authorized employees of the Contractor and each of their participating pharmacy providers.

2) The designated/authorized employees of the FSC, and/or

3) Any third party as deemed necessary by the Contractor, each participating pharmacy provider and the FSC.

4) The Contractor, as a business associate of the FSC under the terms of the contract will comply with all requirements and provisions regarding Privacy, Protected health Information (PHI) and Security as required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996 (Public Law 104-191).

9.0 Network Certification and Administration:

1. The Contractor shall maintain complete provider certification documents on all providers and make them available for review by the FSC, upon request. Accompanying all new certification documents will be the following provider licensure information:

1) Drug Enforcement Agency (DEA) identification number by pharmacy

2) State pharmacy license number by pharmacy

3) NCPDP number (formerly called National Association of Boards of Pharmacy NABP) of each pharmacy

4) Internal pharmacy designated number (applies only to pharmacy chains or multi-locations i.e. Store Number)

5) Complete address of each pharmacy including telephone number

6) Federal tax identification number of each pharmacy/pharmacy chain

7) Provider’s NPI (National Provider Identifier) from NPPES (National Plan & Provider Enumeration System)

10.0 Databases:

a. The Contractor shall ensure that all Contractor reference database files are maintained and updated weekly to include the most recently published information. Those files include, but are not limited to, DEA provider files, MediSpan, First DataBank, Micromedex, NCPDP pharmacy provider file, HCIdea and the NPI.

b. FSC utilizes MediSpan for identifying NDCs and drug pricing.

11.0 Audits:

a. The Contractor shall retain the submitted electronic transactions and any other source documentation for a period of no less than 75 months from the date of service. After 75 months the contractor shall have the media sanitized per NIST Special Publication 800-88 that held any FSC files containing beneficiary information.

b. The FSC, or any authorized representative, has the right to conduct an audit during normal business hours at the Contractor’s site at no cost to the government, and confirm any source documents (such as the prescription form, the NCPDP prescription data captured on-line from the provider, or any documents used to bill the FSC) that are relevant to claims submitted to the FSC electronically. Incorrect payments, which are discovered because of such an audit, will be adjusted in accordance with VA guidelines and applicable program provisions. The FSC may request ad hoc reports (regarding costs, time frames, etc.) on a case-by-case basis. The Contractor will provide adequate space and any source documents or reports needed by the FSC to verify compliance at no charge to the FSC.

c. The FSC may request that the Contractor perform audits of certain network pharmacy providers when fraud, abuse or other aberrant activity is suspected, which will be conducted at no additional (over and above) expense to the Government.

d. The Contractor shall notify the FSC of any audits performed as a result of the Contractor’s Quality Assurance Plan.

12.0 Reporting:

a. The Contractor shall provide a list of available monthly/periodic reports summarizing claim data and identifying trends, averages, utilization rates and other such information needed to effectively track the FSC expenditures and drug utilization.

b. The reports will include, at a minimum:

1) Total Number of Prescriptions

2) Total Number of Brand Name Prescriptions

3) Total Number of Generic Prescriptions

4) Total Cost of All Prescriptions

5) Total Cost of Brand Name Prescriptions

6) Total Cost of Generic Prescriptions

7) Annual Report on Program Costs

c. These reports, and any other agreed upon, will be prepared in a FSC-approved format. Crosswalks will be included in all pharmacy (NPI and NCPDP) and prescriber (NPI to DEA) reports. Reports will be electronically generated and transmitted by Secured Filed Transfer Protocol by the 7th day of the following month.

d. The Contractor shall provide the FSC with a list of available retrospective detailed Drug Utilization reports (DUR) to identify over utilization or abuse of medications by the FSC beneficiaries and to suggest more cost-efficient options.

e. The Contractor may be required to provide additional adhoc utilization reports related to electronically filed claims. Examples may include: Top 100 drugs, Brand and Generic quantities prescribed, Brand and Generic costs or other such data as required by the FSC. These will be on an as needed basis as determined by the Contracting Officer’s Representative (COR) or other designated representative.

f. The Contractor shall provide samples of all reports at the time of proposal submission. Award of the contract does not imply acceptance of any sample reports or formats. After award of the contract, the Contracting Officer or COR will approve specific reports on an individual basis.

g. Annually, the Contractor shall provide a year-end review and briefing at the VA FSC facility which will include summaries of the cumulative year end reports. The time allotment estimated for the briefing will be two (2) hours.

13.0 Training:

a. The Contractor shall provide orientation and instructions to their employees regarding VA programs, benefits, claims, and customer service.

b. The Contractor, in consultation with VA, will prepare and implement a training program for all support staff personnel who will have routine contact with Veterans and beneficiaries, to provide a basic overview of VA programs, available sources of Veteran assistance and an understanding of the core claims process. Information concerning referral to VA's health care system will also be provided.

c. All Contractor staff will complete the annual privacy and security training provided online by the VHA.

d. Completion certificates shall be provided to the COR and the Contracting Officer for the official file.

e. The Contractor shall establish and implement a training plan to ensure that its staff and subcontractors are knowledgeable and trained regarding the requirements of the FSC programs and its administration under this contract.

f. The plan will be approved post award by the Contracting Officer or COR. Award of the Contract does not imply acceptance of the plan.

14.0 Key Personnel:

a. The Contractor shall provide a description of key personnel in the technical proposal.

b. The Contractor shall not replace key personnel without prior approval of the Government, as the contractor deems necessary and/or if performance does not conform to the requirements of this PWS.

c. The Contractor’s key personnel shall be timely in their responsiveness to Contracting Officer or COR at all times.

d. Upon award, the Contractor shall provide a list with phone number and e-mail information for all key personnel (to include their title and responsibilities) that will assist with administration of this contract.

15.0 Prime and Subcontractors:

a. The Contractor shall provide documentation if there is intent to use a subcontractor to meet the requirements of this proposal.

b. The Prime Contractor shall complete at least 50% of all work described in the proposal with staff that they themselves employ. The Government will not entertain a “pass-through” contractual structure.

c. All proposed first tier subcontractors will be identified and a list will be furnished that includes subcontractor demographics and all functions that will be provided to the prime Contractor.

16.0 Professional and Industry Participation:

a. The Contractor shall provide a statement representing its or its employee’s participation in Industry Standards Development Organizations (SDOs) and other pharmacy professional or technical organizations.

b. The Contractor shall indicate the organization name, and number of employees actively participating and the time participating in these SDOs (e.g. NCPDP, ANSI X12, WEDI, HL7, AMCP, NACDS, APHA, NCA, etc.).

c. The Contractor shall be seeking URAC certification.

17.0 Transition (Phase-In/Phase-Out):

a. Phase-in performance consists of all the preparation activities, including but not limited to making capital expenditures, ensuring a qualified workforce is in place, providing appropriate training, and implementing the information technology support necessary to fully perform the requirements contained in this performance work statement and contract within 30 days after contract award.

b. The Contractor will begin performance of all requirements under this contract on date of contract award. After a 30-day period the contractor shall be fully (100%) operational per the requirements of this PWS, and the transition phase shall be completed.

c. The Base Period will be one (1) year and begin on date of contract award. Any additional options years awarded, will be one year in duration.

d. Upon conclusion of the contract, the Contractor shall participate in a phase-out period not to exceed 75 days.

e. The contractor shall provide a transition plan that outlines the designated time period and strategy to transition into the duties as the contractor and to transition out of the contract at the end of the period of performance. The transition period shall not exceed 30 days.

18.0 SPECIFIC TASKS AND DELIVERABLES

TASK & DELIVERABLES TABLE 1 - List of Deliverables

Compliance/ On-time delivery.

Compliance/ On-time

100% review by COR. CO shall provide notification of acceptance/rejection.

Within noted timeframes within PWS. 100% Compliance/ On-time delivery.

Training Certificates 1 week after contract award and annually.

SSAE-16 Audit Report Annually after contract award

Delivery Instructions

Copies of deliverables shall be furnished to the appropriate Government personnel per Table…