Statement of Work- PBMS DRAFT.pdf

STATEMENT OF WORK (SOW)

1. Description of Service

The VA Central Iowa Health Care System (VACIHCS) is seeking a Contractor to provide pharmacy benefit management first-fill services. The contractor shall fill original prescriptions written by authorized VA providers for patients seen at these facilities and the associated Community-Based Outreach Clinics (CBOCs) and provide medication counseling per Omnibus Budget Reconciliation Act of 1990 requirements (OBRA-90).

Prices shall be offered with respect to Average Wholesale Price (AWP).

2. Locations Covered

VA Central Iowa Health Care System 3600 30th Street Des Moines, IA 50310

And associated VA Clinics and CBOCs

Carroll VA CBOC 311 South Clark Street, Suite 275 Carroll, IA 51401

Fort Dodge VA CBOC 530 South 25th Street Fort Dodge, IA 50501

Knoxville VA CBOC 1607 North Lincoln Street Knoxville, IA 50138

Marshalltown VA CBOC 201 East Merle Hibbs Boulevard Marshalltown, IA 50158

Mason City VA CBOC 478 Tiffany Drive Mason City, IA 50401

South Des Moines VA Clinic 1211 East Army Post Road Des Moines, IA 50315

DRAFT

3. Period of Performance

This is a single award IDIQ for five (5) years, from 07-01-2025 to 06-30-2030:

Ordering Period Begins Ends 1 07-01-2025 06-30-2026 2 07-01-2026 06-30-2027 3 07-01-2027 06-30-2028 4 07-01-2028 06-30-2029 5 07-01-2029 06-30-2030

4. Estimated Quantities

The following estimates are estimated amounts based on the VA's historical needs. The estimates are not a guarantee to the Contractor. Actual cost or quantity may be equal, lesser, or greater than the estimate below.

Facility Location Estimated Number of Generic and Brand Name

Prescriptions Filled (Five Year Period of Performance)

VA Central Iowa Health Care System and associated VA Clinics and CBOCs

6,000

5. Scope of Work

The contractor shall provide a pharmacy network that will allow Veterans to receive medications pursuant to a valid prescription from an authorized VA provider. The medical facility will provide a list of formulary medications that will be approved for reimbursement. Any medications not on the formulary list would require an override approval. The medical facility will provide and maintain a list of approved prescribers.

The provider network will be limited to providers approved by the medical center.

The Contractor will provide pharmacy benefit management first fill services. Contractor shall fill first time prescriptions for patients seen at these facilities and the associated Community Based Outreach Clinics (CBOCs) and provide medication counseling per Omnibus Budget Reconciliation Act of 1990 requirements (OBRA-90). Prices shall be offered with respect to Average Wholesale Price (AWP).

Contractor shall provide a list of potential pharmacies that fit the demographic requirements (within 5 miles of the main facility and affiliated CBOC locations listed above). From this list, CI will choose which pharmacies they would like to use for the services based on location, parking, and other veteran convenience factors as determined by each facility.

After a selection has been made, the Contractor shall create a custom network such that only the chosen pharmacy can be used for prescriptions from the providers from each facility.

6. Hours of Operation

Pharmacies should have standard operating hours that would allow Veterans the opportunity to fill prescriptions without significant inconvenience.

Federal holidays are:

New Year’s Day Martin Luther King Jr.'s Birthday President’s Day Memorial Day Juneteenth Independence Day Labor Day Columbus Day Veterans Day Thanksgiving Day Christmas Day *Any day specifically declared by the President of the United States to be a nationally observed holiday.

General Requirements

Prescription Fill Process

1. DESCRIPTION OF WORK/SPECIFICATIONS:

1.1. Prescriptions filled shall be in electronically prescribed, written, verbal, or faxed form provided by authorized VA providers assigned to the facility and CBOCs.

1.2. The Contractor shall establish a pharmacy network that has a single pharmacy identified for each the main facility and affiliated CBOC locations listed in this Statement of Work. The Contractor may only use, on a case-by-case basis, an authorized pharmacy outside of the established pharmacy network with prior approval of VA Central Iowa Health Care System, Chief of Pharmacy, or designee. The pharmacy network must be presented to Central Iowa Chief of Pharmacy for approval prior to starting performance. The Contractor shall establish a provider network comprised of VA providers affiliated with and performing patient care services at VA Central Iowa Health Care System and affiliated CBOC locations listed in this Statement of Work. The Contractor may only use, on a case-by-case basis, a non-VA provider outside of the established provider network with prior approval of VA Central Iowa, Chief of Pharmacy, or designee.

1.3. The authorized voucher for that specific location must accompany the patient’s prescription. The contractor shall provide voucher forms with appropriate billing and customer service information as well as the ability to track utilization by VA specific location.

1.4. Prescriptions shall be filled and dispensed only for medications and/or supplies prescribed by authorized VA providers.

1.5. The VACIHCS will create a formulary also called an Emergent Drug List. Any medications not on the Emergent Drug List (EDL) will require approval by a VACIHCS pharmacist prior to being filled. The VACIHCS formulary will be forwarded to the contractor after each revision by the Chief, Pharmacy, or their

1.6. Prescriptions filled and dispensed through emergent fill contracts will be limited to medications of urgent need as determined by VA clinical staff and will follow safe and effective formulary management principles practiced within the VA.

This may include adjudication of medications on a case-by-case basis as defined by local medical center procedure. CI will maintain an emergent drug list of medication the contractor may fill without prior authorization. The Chief of Pharmacy or designee will email this “emergent drug list” to the Contractor at the time of contract award and provide updates to the list as necessary. There shall be a mechanism in place, provided by the Contractor, to provide real time messaging and hard edits to the pharmacies to limit dispensed medications to the specified “emergent drug list” and to prevent medications that require prior authorization from being dispensed. Medications not on the “emergent drug list” will not be filled and dispensed without prior approval by authorized CI pharmacy personnel.

1.7. The VACIHCS will provide a list of approved VA providers that can have prescriptions filled thru this contract. This list of approved VA providers will be forwarded to the contractor after each revision by the Chief, Pharmacy, or their

1.8. Prescriptions shall be filled and limited to a maximum of ten (10) days’ supply except for: one vial of insulin on local formulary, one inhaler on local formulary, and a maximum of fourteen (14) days’ supply of antibiotics on local formulary or limited to restricted quantities as listed in the formulary.

1.9. No refills will be authorized. The contractor shall fill NEW PRESCRIPTIONS

ONLY!

1.10. Reimbursement shall be determined by the average wholesale price (AWP) discounted by the applicable percentage plus the applicable dispensing fee. The total price charged to the VACIHCS shall not exceed that charged to the public and shall not exceed the price charged by the contractor’s lowest third-party reimbursement.

1.11. AWP (average wholesale price) shall be based on the current Pharmacy

Fundamental Reference REDBOOK and REDBOOK Updates published by Medical Economics Data, Inc., the AWP Medispan or First DataBank pricing schedule and whichever is most advantageous to the government.

1.12. Prescriptions filled under this contract shall be generic drugs ONLY. If medication is available from a manufacturer in generic form, it should be provided to the patient. If the generically manufactured product is unavailable at the time of Veteran need (i.e., shortage), Contractor staff is to obtain prior authorization approval from a VACIHCS pharmacist prior to filling that medication for the Veteran.

1.13. The VACIHCS’s beneficiaries will pick up their own prescriptions at the dispensing pharmacy. No prescriptions are to be mailed. No prescriptions are to be delivered. Veterans are not to be charged by the contracted pharmacy under this contract for the prescription dispensed under this contract.

1.14. All prescriptions must have proper auxiliary labels attached and appropriate counseling and drug interaction sheets provided.

1.15. The contractor shall report all adverse drug events reported by the VACIHCS's beneficiaries to the Pharmacy Department at the VACIHCS and to the prescribing provider.

1.16. The Government reserves the right to fill any prescription covered under this contract using its own resources and/or staff.

1.17. Services provided under this contract will be monitored by the Contracting

Officer's Technical Representative (COTR) as designated.

1.18. If the contract pharmacy is having difficulty with any claim or any other situation, they will contact the contractor. The contract pharmacy will not contact employees of the medical facility (VACIHCS).

1.19. The contractor shall not make authorizations to the contracted pharmacies for prescriptions that fall outside of the normal constraints as stated within. If this occurs, the contractor will be responsible for reimbursing the VACIHCS pharmacy for the prescription.

1.20. VA reserves the right to fill any prescription using its own resources and/or personnel.

Audits

The VA will randomly audit prescription fills at their discretion. The VA shall have access during regular business hours, and upon reasonable notice, to such books, records, invoices, and prescription files as deemed necessary to verify claim information, prescription volume, and the usual and customary charges to the public for covered prescriptions. The Contractor shall make all prescription records and invoices available at the time of the audit. The Contractor shall provide each facility with detailed monthly reports which include patient, provider, date(s) of service, medication, and cost information broken down by main facility and affiliated CBOC locations for auditing.

Contract pharmacies shall maintain a log of VA prescriptions filled and have the patient sign next to each prescription number for each prescription received. A copy of the log shall be maintained at the contract pharmacy and be readily accessible for random VA audit.

The Chief, Pharmacy, or their designee, at VACIHCS shall review the monthly statements provided by the contractor regarding prescription fills at the local emergent fill pharmacies. Should discrepancies be discovered in the billing, a request will be made by the facility to the contractor to provide a copy of the consult in question.

If the prescription in question is not able to be produced within 10 calendar days, the contractor will adjust the statement by the amount in question. This review process will only be available for 90 days after the date of the prescription fill in question. Thus, the contract pharmacies will only be required to keep the hard copies available for 90 days.

Privacy Requirements

The contractor shall comply with the requirements of the Federal Privacy Act of 1974 (Public Law 93-579), HIPAA (Public Law 104-191), and the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation Act of 1972 (Public Law 83-255), as well as other statues regarding confidentiality of patient information during and after the execution of this BPA.

The contractor and the contracted pharmacies shall keep all information concerning VA beneficiaries confidential and shall not release or disclose information to any person, except as authorized in writing and according to all applicable laws.

The contractor shall not store patient information on a mobile device. A verbal contact is sufficient to obtain prior authorization when needed. The Contractor is prohibited from transferring Personal Health Information (PHI) by fax or email to and/or from a VA facility.

The contracted pharmacies including subcontracted pharmacies that are authorized to fill prescriptions under the BPA and subsequent task orders must agree to the following conditions:

1. All information concerning VA beneficiaries shall be kept confidential and shall not be disclosed to any person, except as authorized in writing from VA, and according to all applicable laws.

2. Representatives of the VA are authorized to visit the contractor’s sites and the premises of any pharmacy filling VA prescriptions during regular business hours for the purposes of auditing and evaluation, which may include the inspection of clinical records.

3. The contractor shall report all adverse drug events reported by VA beneficiaries to both facilities’ Chief of Pharmacy, COR, to the prescribing CBOC provider, and Emergency Room provider if applicable.

4. Pharmaceutical services provided to VA beneficiaries shall meet all standards applicable to Medicaid recipients in the State where services are provided, and standards set forth in the current version of The Joint Commission accreditation manual for Ambulatory Care/Pharmaceutical Services.

Licensing and Qualification Requirements

Pharmacies utilized by the contractor shall be in good standing with their respective State Board of Pharmacy utilized by the contractor shall have a current Drug Enforcement Administration (DEA) license, controlled substance license, and general license from the respective State Board of Pharmacy.

Pharmacists Requirements:

• Graduate of an Accreditation Council for Pharmacy Education (ACPE) College of

Pharmacy

• Licensed and in good standing with the Iowa State Board of Pharmacy.

Pharmacy Requirements:

• Current general pharmacy license in good standing with the Iowa State Board of

Pharmacy

• Current DEA license in good standing

• Current controlled substance license in good standing DRAFT

STATEMENT OF WORK (SOW)