Section C Statement of Work.pdf

SECTION C

STATEMENT OF WORK

C.1. Program Description

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

The mission of the MHS is to enhance DoD readiness and national security by providing health support for the full range of military operations. The MHS must be prepared not only to provide a high quality, cost-effective health care benefit to its eligible beneficiaries 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 Medical 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 beneficiaries. The TRICARE Pharmacy Benefits Program 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 TRICARE 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 with input from the Beneficiary Advisory Panel (BAP) and final approval through DHA Director.

This establishes the basic program benefits. Prescriptions for selected agents and supplies, hereafter referred to collectively as “agents” may be subject to prior authorization (PA) or utilization review requirements to assure Medical Necessity (MN), clinical appropriateness, and/or cost-effectiveness. There are statutorily required tiered cost-sharing by which beneficiaries partially defray costs of administering the pharmacy benefits program. Cost-sharing amounts differ based on the classification of an agent as generic, formulary, or non-formulary, in conjunction with the Point of Service (POS) from which the agent is acquired. The mail order and retail portions of this benefit are open to all eligible TRICARE beneficiaries.

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

C.1.1. Overall Program Objectives The following objectives identify the desired outcomes of this contract and are supported by the technical requirements in Section C:

• Efficient, accurate, and timely processing of claims and clinical review across all points of service, in accordance with the TRICARE benefit design, policy, regulation, and law.

• Convenient and timely beneficiary access to all agents covered by the TRICARE pharmacy benefits Program.

• Superior levels of agent care, safety, and beneficiary satisfaction.

• Effective management, quality controls, and oversight of all services and functions.

• Competitive cost management and optimized cost avoidance, cost containment, and use of

Government resources.

• Delivery of the TRICARE Pharmacy Benefits Program through secure and reliable systems that promote seamless and streamlined operations for prescribers, beneficiaries, and other MHS stakeholders.

C.1.2. Definitions Definitions specific to this contract, or not otherwise in Appendix A of the TRICARE Operations Manual, are provided in J-1.

C.1.3. Government Furnished Information

C.1.3.1. The Contractor shall interface with the Defense Enrollment Eligibility Reporting System (DEERS), according to the requirements established in the TRICARE Systems Manual.

C.1.3.2. The Government will provide licenses for the Contractor to access and use DEERS applications.

C.1.3.3. The Government will provide the Contractor with access to a medical pricing catalog which will be used for replenishment, at TMOP and for adjudicating federal electronic health record (EHR) claims.

C.1.3.4. The Government will provide initial Interface Control Documents (ICDs) and some additional technical specifications for the following systems:

• PDW

• Forensic Toxicology Drug Testing Laboratory Information Management System

(FTDTL IMS)

• Immunization Tracking System

• Operational Medical Data Store (OMDS)

• Federal electronic health record

C.1.3.5. The Government will provide a quarterly data file for beneficiary mailings related to formulary changes, described under C.9.3.3.

C.1.3.6. The Government will provide a no less than quarterly file of beneficiary zip codes for use in evaluating and reporting on compliance with network access standards.

C.1.3.7. The Director’s Communications and Public Affairs Division of the Defense Health Agency (DCPAD) will design, develop, and print beneficiary educational materials, including written materials, briefings, and other methods of publicizing the TRICARE Pharmacy Benefits Program, 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.

C.1.3.8. The Government will provide the PDW Data Dictionary and Data Schema, as described under C.11.8.

C.1.3.9. Before the start of pharmacy services, the Government will provide (via previous contractors) batch files containing all retail, mail, and MTF claims along with PA and MN determinations for the past two-year period. The Government (via the outgoing contractor) will also provide an Other Health Insurance (OHI) data file.

C.1.4. Requirements Documents

C.1.4.1. The following documents are hereby incorporated by reference and form an integral part of this contract. Documentation incorporated into this contract by reference has the same force and effect as set forth in full text.

• Title 10, United States Code, Chapter 55

• 32 CFR Part 199

• TRICARE Policy Manual (TPM) 6010.63-M, April 2021

• TRICARE Reimbursement Manual (TRM) 6010.64-M, April 2021

• TRICARE Systems Manual (TSM) 7950.43-M, April 2021

• TRICARE Operations Manual (TOM) 6010.62-M, April 2021

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

C.1.4.2. TRICARE Manuals.

C.1.4.2.1. The TRICARE manuals provide instruction, guidance, and responsibilities in addition to the requirements set forth in the incorporated federal statutes and regulations listed in C.1.4.1 and may not be interpreted in contradiction thereto.

C.1.4.2.2. The Contractor shall utilize the current version of the TRICARE Manuals T-5, published at Attachment J-3, line 11. The manuals are applicable in their entirety.

C.1.4.2.3. The Contractor shall routinely review proposed, postponed, and published manual changes and discuss concerns with the Contracting Officer Representative (COR).

C.1.4.2.4. When a new manual change is postponing a publication (identified with a change number and date), the COR and Contractor will coordinate to confirm the applicability of a change to the contract.

C.1.4.2.5. To the extent practicable, for those manual changes that apply to the contract, the Government and Contractor will negotiate in good faith a bilateral agreement that incorporates the change into the contract. This in no way precludes the Government’s exercise of its rights to execute unilateral change orders as circumstances may require.

C.1.4.2.6. Manual changes that do not apply to the current contract will be incorporated into the next modification of the contract.

C.1.4.2.7. Among the manuals, the TRICARE Policy Manual (TPM) takes precedence over the other three TRICARE Manuals. The TRICARE Reimbursement Manual (TRM) takes precedence over the TRICARE Systems Manual (TSM) and the TRICARE Operations Manual (TOM). The TSM takes precedence over the TOM. In the event of conflict between language found within the TRICARE manuals and the contract, the contract prevails.

C.2. General Claims Processing.

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

C.2.2. Unless stated otherwise, the Contractor shall include claims adjudication processes outlined in C.2, consisting of eligibility check, application of the correct cost-sharing amount, identification of OHI, benefit design edits, Drug Utilization Review (DUR) 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. The Contractor shall maintain a complete patient profile, inclusive of all claims processed within the scope of this contract.

C.2.3. Appeal Rights. The Contractor shall not accept appeals from Active Duty Service Members (ADSMs). ADSMs are not authorized as appealing parties for TRICARE cost-sharing determinations. ADSMs should be directed to their local MTF for review of access to care issues.

C.2.4. The Contractor may, as a courtesy to beneficiaries, perform internal coordination of benefits between TMOP and contractor- administered OHI to prevent the beneficiary from having to submit a separate reimbursement claim.

C.2.4.1. If the Contractor receives a prescription or supporting documentation (e.g., reimbursement claim, PA request) for a beneficiary with Contractor-administered OHI, the Contractor shall internally transfer to its commercial operation in lieu of rejecting or returning to source.

C.2.4.2. If the Contractor receives a prescription or supporting documentation through its commercial operational process for a beneficiary with TRICARE, the Contractor shall process the commercial as primary and automatically submit the secondary claim to TRICARE, billing the beneficiary for any amount remaining after the TRICARE secondary coverage is applied.

C.2.5. Claims Processing System

C.2.5.1. The Contractor shall provide 24 hours a day, 7 days a week claims processing for all locations, including overseas MTFs.

C.2.5.2. The Contractor’s claims processing system shall be available no less than 99.5% of the time, excluding external interface partner downtime. The system is unavailable when the rate of certain claims rejects exceeds 10% for at least 30 minutes. These rejects include those tied to system non-availability, based on mutual agreement with the Government, and documented in CDRL M060. Contractor downtime concurrent with external system downtime is excluded from the system availability calculation.

C.2.5.3. The Contractor shall provide reporting on system processing performance per Contract Data Requirements List (CDRL) M060. At the request of the Government, the Contractor shall provide documentation of reported downtime, including detailed explanation of the causes.

C.2.5.4. The Contractor shall immediately communicate unscheduled downtimes of no fewer than 15 minutes to MTF pharmacy staff and other recipients identified by the Government.

System availability updates will be provided at a Government determined interval and will include an estimate of when the system will once again be available for use. A final notification shall take place to inform users that regular processing has been restored. The communication mechanism shall be provided and maintained by the Contractor.

C.2.5.4.1. The Contractor shall schedule maintenance windows, to the greatest extent possible, to coincide or overlap with Defense Manpower Data Center (DMDC) maintenance windows, as described in TSM Chapter 3, Section 4.2. The TSM reflects a maximum window within which DMDC scheduled maintenance will occur. Actual planned duration is communicated by DMDC on a weekly basis (See C.11.5.2.). DMDC will attempt to accommodate the Contractor’s needs when establishing a maintenance schedule.

C.2.5.5. The Contractor shall notify the Government no less than 72 hours in advance of any planned maintenance window outside the DMDC maintenance window. The Contractor shall also send a final notification to inform users that regular processing has been restored. Such notifications shall include MTF pharmacy staff and other recipients identified by the Government, through the process underC.2.5.4 .

C.2.5.6. 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 because of having more than one sponsor.

C.2.5.7. The Contractor shall ensure that their system utilizes software which maximizes configurable parameters to allow for changes to be made quickly and efficiently.

C.2.6. DEERS

C.2.6.1. Verifying Eligibility. The Contractor shall not authorize payment for a prescription prior to verifying eligibility, except at the direction of the Government.

C.2.6.1.1. In some cases, the Government may authorize the Contractor to process one or multiple claims regardless of DEERS eligibility or date of service. Any necessary overrides must be available to allow for real-time electronic claims and paper claims to process at any pharmacy point of service.

C.2.6.2. The Contractor shall minimize queries to DEERS that are not required for the purpose of authorizing payment or obtaining demographic data to correctly apply benefit design rules.

C.2.6.2.1. The Contractor shall monitor DEERS query volumes for all interfaces throughout the period of performance against the projections provided during transition. The Contractor shall investigate the variance in these volumes and revise estimates for future periods of performance annually, or any time that the actual query volume(s) deviates more than 10% from the most recent projections (CDRL A090).

C.2.6.2.2. The Contractor shall optimize their system to reduce timed-out transactions to DEERs.

C.2.6.3. Catastrophic Cap and Deductible (CC&D)

C.2.6.3.1. The Contractor shall use the beneficiary’s CC&D status to apply the correct cost-sharing amount and deductible and perform updates in accordance with TOM Chapter 23, Section 3. Separate catastrophic caps are maintained for Continued Health Care Benefits Program (CHCBP), in accordance with TOM Chapter 23, Section 3.

C.2.6.3.1.1 The Contractor shall receive and provide reporting on the maintenance of CHCBP catastrophic caps (CDRL Q120)

C.2.7. Claims Processing Edits

C.2.7.1. The Contractor shall support claims adjudication rules specific to the POS.

C.2.7.2. The Contractor shall apply comprehensive edits at the point of dispensing in accordance with the appropriate benefit design in force for that date and POS and commercial best practices.

New claims shall be screened against the complete patient profile (see C.2.3). The Contractor shall return appropriate clinical warnings or administrative alerts.

C.2.7.3. The Contractor shall perform real-time edits that may be specific to DoD and fall outside standard commercial practice, including but not limited to Prescription Monitoring Program, sanctioned providers, safety reviews established through the Uniform Formulary process, prescriber status, DEERs data (e.g., beneficiary category, AD status), and the ability to suppress real-time edits by POS based on Government direction.

C.2.7.4. 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 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.

C.2.7.5. 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.

C.2.7.6. State of Emergency (SOE) Declarations

C.2.7.6.1. The Contractor shall monitor SOE declarations issued by Federal and State Governments and provide a recommendation start and end date for the implementation of emergency refill too soon procedures. The recommendation will include the start and end date of the SOE as provided by the Governor, state, or issuing agency. The Contractor’s recommended start date should coincide with the date when the recommendation was made to the Government.

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

C.2.7.6.2. The TMOP shall not ship agents to areas under a declared emergency without confirming that both delivery by carrier and receipt by beneficiary are possible. For packages shipped prior to the emergency declaration that were reported lost or missing, the Contractor shall immediately ship the replacement to the beneficiary’s alternate address and refund copay for the lost shipment upon request per C.6.2.11 and C.6.2.12

C.2.7.6.3. The Contractor shall provide standard emergency operating procedures which address the following:

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

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

• Maintain communication channels to keep stakeholders informed, including:

o Beneficiaries: how they can receive their agents, in coordination with DCPAD.

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

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

C.2.7.6.4. The Contractor shall document policies and processes for SOE declarations in playbooks and make available to the Government up request.

C.2.7.6.5. After an event, the Contractor shall provide monthly reporting on the overrides that were granted under the Emergency procedures (CDRL R070). An event may be comprised of several individual Emergency Declarations (i.e., a hurricane that impacts several counties and states).

C.2.7.6.6. The Contractor shall not send off hours SOE requests to the Government unless prepared to act upon the response on the same day it is received during off hours.

C.2.8. Other Health Insurance (OHI)

C.2.8.1. The Contractor’s OHI file shall be the system of record for OHI. The Contractor shall utilize all possible data sources to maximize the identification of OHI, including but not limited to leads provided by the following:

• Managed Care Support Contractors (MCSC)

• MTF COB claims

• Agent manufacturers

• Claim forms

• Beneficiary declarations

• Contractor’s internal files

• Commercial services or data sources

C.2.8.2. The Contractor shall develop OHI records in accordance with TOM, Chapter 23, Section 3, TOM Chapter 10, Section 4, and TRM, Chapter 4.

C.2.8.3. If OHI information between sources is inconsistent, the Contractor shall utilize logic to determine which source is the most reliable in a quick and efficient manner.

C.2.8.3.1. The DEERS eligibility system will provide an indicator of Medicare Part D (MPD) enrollment. The Contractor may utilize this information or use an alternative approved source for determining MPD coverage status.

C.2.8.3.2. The Contractor shall track and mitigate discrepancies between DEERS MPD information or alternative MPD source (see C.2.9.3.1) and information conveyed by the beneficiary. If a beneficiary notifies the Contractor that their MPD status is not correct in the system, the Contractor shall have a process to document the correct MPD status and adjudicate claims based on the updated status. Unless there is a request for reimbursement, the Contractor shall accept the beneficiary’s attestation of coverage or lack of coverage.

C.2.8.3.3. In cases where DEERS or alternative MPD source did not reflect MPD coverage that was in place, the Contractor shall also provide reimbursement for past claims where the patient’s copay exceeded what is allowable with MPD. The Contractor shall ask for appropriate documentation to verify coverage dates. For reimbursement request of claims dated prior to 1 Jan 2023, the Contractor shall request approval from the Government.

C.2.8.3.4. The Contractor shall use the Processor Control Number (PCN) submitted on each incoming COB claim. If the MPD PCN is used on the claim submission, the Contractor shall treat the incoming claim as an MPD claim in all respects. The submitted PCN shall take precedence over all other data sources.

C.2.8.4. 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 their system as necessary.

C.2.8.5. 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.2.8.6. The 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.

C.2.8.7. The Contractor shall provide reporting to the Government on OHI development (CDRL Q110) and cost avoidance (CDRL Q111).

C.2.9. Claims Processing System Documentation

C.2.9.1. The Contractor shall develop and maintain comprehensive documentation of all aspects of claims processing not covered in the benefit design document (see C.2.9.4), including but not limited to OHI/COB, Medicare Part D Claims, pricing logic, thresholds for specific edits (eg, refill too soon), rules specific to a point of service (including MTF Set-Up Document – see C.5.4), and any other claims adjudication rules currently in use that are not defined by the DoD P&T or by law.

This combined 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 in accordance with C.14.13.

C.2.9.1.1. Current documentation shall be made available to the Government prior to Benchmark Testing during transition and be used to evaluate results.

C.2.9.2. The Contractor shall maintain all payer sheets used in the transmission of DoD claims from all POS.

C.2.9.3. 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, enrollment category, POS, agent by category, law and regulation, and any other factors, The benefit design document will include the following lists:

• MTF Basic and Extended Core Formularies

• Compound inclusions and exclusions

• Covered over the counter (OTCs) to include agents specifically covered for the federal EHR

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

• Non-Formulary Agents

• PA

• Step-Therapy Agents

• Self-Administered Injectables

• Smoking Cessation Agents

• Specialty Agents

• Covered Vaccines

• Non-covered Agents

• Quantity Limit (QL) Restrictions

• Age restrictions

• Expanded Mail Order and MTF drug list (specialty and non-specialty)

• Agents Cost Exceed Max List

C.3. Retail Prescriptions

C.3.1. Retail Prescription Claims

C.3.1.1. The Contractor shall accept and process all claims for agents and supplies covered under the TRICARE Pharmacy Benefits Program 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.

C.3.1.2. The Contractor shall limit retail claims for covered agents under 10 U.S.C. §1074g, 32.C.F.R.

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. Reimbursement of retail pharmacy claims will be made in accordance with G.3.6.2.

C.3.1.4. When access to specific agents at retail pharmacies is restricted under the law, 32 CFR

199.21 (r), the Contractor shall facilitate either a change in the beneficiary’s current prescription to an approved agent or shift the beneficiary’s prescription to TMOP. Covered agents 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)

C.3.1.5. When claims are received that are out of jurisdiction for the TRICARE Pharmacy Contract, the Contractor shall forward them to the TRICARE Contractor with jurisdiction for those claims, in accordance with TOM, Chapter 8, Section 2 and TOM Chapter 23, Section 2.

C.3.1.6. The Contractor shall complete real-time, online Coordination of Benefits (COB) in accordance with National Council of Prescription Drug Program (NCPDP) F6 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 agent expenditures for each TRICARE beneficiary who is also enrolled in Part D. The Contractor shall provide this information to the Centers for Medicare & Medicaid Services (CMS) designated TROOP facilitator.

C.3.1.7. The Contractor shall reimburse claims in accordance with the TRM, Chapter 4.

C.3.1.8. The Contractor shall process claims submitted by Department of VA pharmacies for beneficiaries who are TRICARE-eligible. These claims shall with processed with TRICARE as primary payer using business rules provided by the Government. VA benefits are not considered

OHI. The Government will provide a list of VA pharmacies to the Contractor. VA benefits are not considered OHI.

1. The Contractor shall determine cost-shares for beneficiaries with Medicare Part D in accordance with TOM Chapter 23, Section 3.

C.3.1.9. 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 copay for each 30-day increment. The Contractor must make this option available at all retail network pharmacies.

C.3.1.10. The Contractor shall ensure that claims for prescriptions filled but not dispensed are reversed within ten (10) calendar days of the date the original claim was submitted. When reversals are processed more than ten (10) calendar days after the date the original claim was submitted, the Contractor shall adjust or cancel the TRICARE Encounter Data (TED) record.

C.3.1.11. 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) and the Contractor shall process these claims regardless of the electronic media (e.g., CD ROM, tapes) through which they are submitted. The Contractor shall process claims from state agencies in accordance with TRM Chapter 1 Section 20. All batch claims shall be processed within two business days of receipt.

C.3.1.12. The Contractor shall report the actual amount paid to the retail pharmacy. On the TED, this will be populated as the Amount Paid by Government Contractor, per the TSM, Chapter 2.

C.3.2. Reimbursement Claims

C.3.2.1. The Contractor shall process reimbursement 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 reimbursement claims is only allowed under an approved Office of Management and Budget (OMB) format.

C.3.2.2. Upon request, the Contractor shall mail the current version of the DD2642 claim form to beneficiaries.

C.3.2.3. The Contractor shall process reimbursement claims for non-network pharmacy services in accordance with the TRM, Chapter 1, Section 15, minus applicable cost-sharing amounts and deductibles.

C.3.2.4. The Contractor shall process these reimbursement claims using the most current NCPDP format.

C.3.2.5. The Contractor shall monitor reimbursement claims processing and work with retail network pharmacies to reduce the volume of network reimbursement claims. Network pharmacies should be using online coordination of benefits in most cases. The Contractor shall work with pharmacies with higher-than-average rates of reimbursement claims to transition them to online processing.

C.3.2.6. The Contractor shall not report or bill manual corrections to retail pharmacy claims as reimbursement claims.

C.3.2.7. The Contractor shall process claims for beneficiaries who are required by their OHI to use their designated mail order pharmacy or other non-network pharmacy using network cost shares.

Non-network cost-sharing amounts and deductibles are not applicable to these claims.

C.3.2.8. The Contractor shall routinely audit reimbursement 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.

C.3.2.9. Measured monthly, reimbursement claims shall meet the following minimum standards:

C.3.2.9.1. 95% of reimbursement claims shall be processed to completion within 10 calendar days of receipt.

C.3.2.9.2. 100% of reimbursement claims shall be processed to completion within 14 calendar days of receipt.

C.3.2.10. The Contractor shall provide reporting on reimbursement claims volumes, processing times, denials and appeals (CDRL Q050). Reimbursement claims are considered processed to completion as of their TED record Create Date.

C.3.2.11. The Contractor shall provide notification to the beneficiary in writing for denied reimbursement claims. The notification must explain why the claims were denied and detail the beneficiary's appeal rights.

C.3.2.12. Under the TRICARE Pharmacy benefits Program, the Contractor shall not process reimbursement 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.

C.3.3. Retail Pharmacy Network

C.3.3.1. 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.

C.3.3.2. Retail Network Access. The Contractor's retail pharmacy network shall meet the following:

C.3.3.2.1. Access Requirements, as measured by beneficiary zip code:

C.3.3.2.1.1 At least one network pharmacy within 15 minutes driving time of 90% of the beneficiaries;

C.3.3.2.1.2 75% of the 10% of beneficiaries that that do not have a network pharmacy within 15 minutes driving time shall have at least one pharmacy within 30 minutes driving time.

C.3.3.2.2. No fewer than 35,000 retail network pharmacies.

C.3.3.2.3. Exclusions

MTF, VA, Public Health Service (PHS), and Indian Health Service (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.

C.3.3.3. The Contractor shall use commercially available software or web tools to calculate this metric. The methodology shall be made available to the Government for audit upon request.

C.3.3.4. The Contractor shall provide reports identifying retail network pharmacies and the total network size (CDRL M040), network access relative to the above metrics (CDRL M041), and network pharmacy performance (Q190).

C.3.3.5. The Contractor shall provide a plan describing how beneficiaries not meeting the access standards will have access to pharmacy services. (CDRL A110)

C.3.3.6. All network pharmacies shall be fully licensed in accordance with applicable Federal and State laws and have a current NCPDP number. Retail pharmacies who offer to mail prescriptions to beneficiaries as part of their business may be included in the network subject to retail pharmacy specifications listed herein.

C.3.3.7. To the extent possible allowed by Federal law and regulation and this contract, retail pharmacies shall provide TRICARE beneficiaries the same type, level, and quality of service provided to beneficiaries of other commercial clients.

C.3.3.8. The Contractor shall ensure that all pharmacies document the receipt of the agent 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.

C.3.3.8.1. The Contractor shall require all retail network pharmacies to utilize online Coordination of Benefits.

C.3.3.9. 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 in the event of network changes:

• Provide the Government with the names of all pharmacies selected for removal from the network at a minimum of 120 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 notification shall provide the beneficiary with names and addresses of the pharmacies closest to the beneficiary remaining in the network. The notification shall include information on how to search for additional pharmacy options. 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 and approve.

• Monitor and track prescription fills by impacted beneficiaries in specific categories

(CDRL R020).

• Make changes to the plan as necessary to ensure successful communication with all beneficiaries and minimum disruption to therapy.

C.3.3.9.1. In situations where a pharmacy fails to meet credentialing standards or there are 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.

C.4. Specialty Agents and Clinical Services

C.4.1. The Government will provide an initial list of agents considered specialty agents.

The Contractor shall propose updates to the list based on changes in the market, evolution of clinical practices, limited access, cost effectiveness, clinical support considerations, and overall benefit to the TRICARE Pharmacy Benefits Program for Government approval.

The Contractor shall provide the methodology under which agents are evaluated and proposed for the addition or removal from the specialty agent list.

C.4.2. Network Pharmacies Capable of Dispensing Specialty Agents. All network pharmacies that can dispense specialty agents shall be fully licensed in accordance with applicable Federal and State laws and have a current NCPDP number. When not dispensed by an MTF pharmacy or a VA pharmacy, all covered specialty agents, including limited distribution agents, shall be accessible to beneficiaries at network retail cost shares or mail order shares if the TMOP dispenses the specialty agent.

C.4.3. The Contractor shall not deny cost-sharing or reimbursement for claims associated with specialty agents filled at network pharmacies unless the specialty agent is enrolled in Expanded Use of MTF and TMOP (C.6.6), subject to benefit design restrictions (C.7.3.1) or agents non-compliant with, 10 USC 1074g(f) as implemented by 32 C.F.R. 199.21(q).

C.4.4. The Contractor shall provide notification to the Government of any changes to the network per C.3.3.9.

C.4.5. Access. The Contractor shall ensure all specialty agents as defined by C.4.1 are available to TRICARE beneficiaries in the pharmacy network. If requested by the Government, the Contractor shall facilitate the movement of specialty prescriptions from MTF pharmacies to TMOP or other network pharmacies.

C.4.6. The Contractor shall provide education on obtaining specialty agents through the network pharmacies if requested by beneficiaries and/or providers. This shall include but is not limited to:

• Education on obtaining agents that have access restrictions (e.g. limited distribution agents).

• Assistance in transferring prescriptions or obtaining new prescriptions.

• Education on all options in the pharmacy network for obtaining a prescription for specialty agents and the benefits of these options within the pharmacy network to allow beneficiaries and providers to make an informed choice.

• Assist in a waiver request if appropriate per C.6.6.

• On-boarding and registration activities at network pharmacies, when appropriate, that can support the dispensing of specialty agent.

C.4.7. Patient Support. The Contractor shall ensure beneficiaries who receive specialty agents from network pharmacies are provided support in accordance with pharmacy best practice standards. At TMOP and Contractor selected retail network pharmacies (if applicable), the Contractor shall provide agent administration support (e.g. patient consultation, therapy evaluation and call center support) that minimizes adverse events. The Contractor shall maximize adherence as appropriate, promote overall well-being and a high level of beneficiary satisfaction as measured by widely recognized industry benchmarks.

C.4.8. Patient Support. The Contractor shall ensure beneficiaries who receive specialty agents from network pharmacies are provided support in accordance with pharmacy best practice standards. At TMOP and Contractor selected retail network pharmacies (if applicable), the Contractor shall provide agent administration support (e.g. patient consultation, therapy evaluation and call center support) that minimizes adverse events. The Contractor shall maximize adherence as appropriate, promote overall well-being and a high level of beneficiary satisfaction as measured by widely recognized industry benchmarks.

C.4.9. The Contractor shall educate beneficiaries on manufacturer supported programs that may augment, but not replace, those services offered by the network pharmacies.

C.4.9.1. At TMOP and Contractor selected retail network pharmacies (if applicable), the Contractor shall provide delivery management services to include timely delivery of agents to align with treatment schedules, delivery tracking and waste prevention.

C.4.9.1.1. The Contractor shall report, per C.6.1.11, the following specialty prescription processing time metrics, specific for TRICARE beneficiaries, for both TMOP prescriptions and Contractor selected retail network pharmacies (if applicable) per CDRL Q040.

C.4.9.2. The Contractor shall ensure beneficiaries receive accompanying supplies for specialty agents dispensed at TMOP and Contractor selected retail network pharmacies (if applicable), including those required for administration, disposal or any other purposes in accordance with pharmacy best practices.

C.4.9.3. At TMOP and Contractor selected retail network pharmacies (if applicable), the Contractor shall work with the MCSC(s) to coordinate agent administration when appropriate (C.15.1.16.4). If required, this shall include the administration or disposal of agents, healthcare provider support or other available services as deemed appropriate.

C.4.9.4. Programmatic Support. The Contractor shall optimize utilization strategies as they relate to C.7.2.1 and the incorporation of industry best practices that align with the TRICARE benefit design. The Contractor shall optimize cost controls.

C.4.9.5. Replenishment at TMOP. The Contractor shall maximize replenishment of specialty agents available from the National Prime Vendor (NPV). The Defense Logistics Agency-Troop Support (DLA-TS) manages the NPV contract (C.6.8.9).

C.4.9.6. Replenishment will be owed to the Contractor when all of the following conditions are met: 1) specialty agents are dispensed from the TMOP to TRICARE eligible beneficiaries; 2) specialty agents are available for replenishment from the NPV; and 3) specialty agents are not acquired through the Market Priced Pharmaceutical Program per C.4.7.6.

C.4.9.7. The Government will work with the Contractor to determine which non-specialty agents are eligible for replenishment at pharmacies designated as replenishment pharmacies to dispense specialty agents per C.6.1. Non-specialty agents determined to be replenishable by the Government will follow the mail order requirements in C.6 and G.3.5.7.3.

C.4.9.8. The Contractor shall request replenishment and follow the requirements in accordance with C.6.8.

C.4.9.9. Non-specialty and specialty agents which are not replenished from the NPV will follow retail prescriptions claims processing per C.3.1.

C.4.9.9.1. The Contractor shall identify its preferred Returns Management Reverse Distributor (Reverse Distributor) to the Government and further distinguish between returns for which replacement of an agent is expected from the NPV per C.6.4.

C.4.9.10. For non-replenished specialty agents, the costs will be reimbursed (see Section G.3.6.1).

Non-replenished agents are subject to cost control measures under the retail network specialty guarantee (See Section H.3.3). In instances where a specialty agent is not replenished in a timely manner, as agreed upon by the Government and the Contractor, the Contractor shall coordinate with the Government to determine the best course of action for continued efforts towards replenishment of specialty agents. This may include but is not limited to: (1) the use of the Contractor’s inventory until replenishment is available through the NPV (C.6.8.13); or (2) utilizing the Market Price Pharmaceutical Program (C.4.7.6 and C.6.8.22). Any replenishment owed at the end of each option period will be reconciled per C.6.8.7.

C.4.9.10.1. If a specialty agent becomes non-replenished from a previous replenished status, the Contractor will provide education to beneficiaries and/or providers on where the agent can be accessed and whether benefit restrictions or co-pay changes may occur.

C.4.9.10.2. If a specialty agent is unavailable at TMOP or the Contractor selected retail network pharmacies (if applicable), the Contractor shall ensure the beneficiary is informed of the situation and will educate the beneficiary and/or provider of their options in obtaining the agent, as well as complete the transfer of that prescription. If appropriate, the Contractor shall work with the beneficiary’s provider to find alternative therapies which may be available at TMOP, or the Contractor selected retail network pharmacies (if applicable).

C.4.9.11. Reporting. The Contractor shall provide a report on the dispensing of specialty agents and clinical services provided (CDRL Q150).

C.5. MTF Pharmacy Claims

C.5.1. The Contractor shall support claims submissions from MTF Pharmacies using the federal EHR.

C.5.2. The Contractor shall connect to sites using the Federal EHR as described in Section C.11.7.

C.5.3. The Federal EHR 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.

C.5.4. The Contractor shall review any changes to claims processing parameters with the Government before they are implemented, including any NCPDP mandated changes to the transaction format such as changes to reject codes and overrides.

C.5.5. The Contractor shall process claims using business rules for the Federal EHR claims, which include the benefit design (including P&T guidance described in C.6.8.22.7) and other documentation (e.g., MTF Set-Up). The Government may direct specific changes to the Federal EHR business rules as appropriate to support mission readiness. The contractor will support pre-deployment activities as it pertains to the various Combatant Commands the deployment falls under per C.6.15.6. up to as outlined in Area of Responsibility (AOR) Mods, such as USCENTCOM MOD).

C.5.6. The Contractor shall support coordination of benefits for the Federal EHR claims, in accordance with the MTF Edit Set-Up document

C.5.7. The Contractor shall support two unique processor control numbers (PCN)s for the Federal EHR claims.

C.5.8. The Contractor shall consult its internal OHI database when processing MTF claims. If the patient is identified as having OHI, the Contractor shall return a reject that is overridable at the MTF’s discretion, without any action by the beneficiary or contacting the MTF Help Desk.

C.5.9. The Contractor shall not enforce eligibility for MTF claims. The MTF assumes responsibility for eligibility; therefore, the Contractor will process the claim regardless of eligibility status.

C.5.10. The Contractor shall not perform CC&D updates for MTF claims.

C.5.11. The Contractor shall maintain current, accurate, and complete system documentation, as described in C.2.9.

C.5.12. The Contractor shall coordinate an interface control document (ICD) with the DHMSM Contractor. The ICD will be approved by the Government.

C.5.13. Federal EHR 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 PDW.

C.5.14. Claims received under C.11.7.1.4 shall be excluded from edits, with no rejects applied.

C.5.15. The Contractor shall adjudicate all Federal EHR 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 agents 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.

C.5.16. The Contractor shall accept the ingredient cost submitted on the claim for the Federal EHR claims. No adjustments or discounts shall be applied.

C.6. Mail Order Pharmacy

C.6.1. Mail Order Pharmacy Prescriptions. The TMOP program, as administered under the terms of this contract, is the Contractor’s Mail Order Pharmacy(s) which supports the dispensing of TRICARE covered non-specialty and TRICARE designated specialty agents.