TRICARE Pharmacy Program RFI (Draft Section C & H)

Statement of Work (SOW) / Performance Work Statement (PWS)

This Statement of Work (SOW) outlines the requirements for a contractor to administer the TRICARE Pharmacy Benefits Program, a Department of Defense (DoD) healthcare program serving approximately 9.5 million active duty and retired service members and their families. The program aims to enhance DoD readiness and national security by providing comprehensive, cost-effective, and high-quality pharmacy services.

The contractor will be responsible for:

• Processing claims efficiently and accurately from various sources including retail network pharmacies, TRICARE Mail Order Pharmacy (TMOP), Military Treatment Facilities (MTFs), VA pharmacies, Indian Health Services (IHS) pharmacies, and beneficiary reimbursements.
• Administering a retail pharmacy network across all 50 states, the District of Columbia, Puerto Rico, U.S. Virgin Islands, Guam, American Samoa, and Northern Mariana Islands.
• Operating TMOP, including dispensing and delivering medications.
• Performing clinical reviews and providing beneficiary and pharmacy support services.
• Managing various systems and interfaces, including the Defense Enrollment Eligibility Reporting System (DEERS), Pharmacy Data Warehouse (PDW), and Federal EHR.
• Handling specialty agents, vaccines, and compound prescriptions.
• Supporting MTF pharmacy claims and mail order pharmacy operations.
• Ensuring compliance with all relevant regulations, policies, and DoD benefit design rules.

The SOW details numerous performance standards, including:

• Claims processing system availability of at least 99.5%.
• Timely processing of reimbursement claims (95% within 10 calendar days, 100% within 14 calendar days).
• Specific call center performance standards for average speed of answer, call blockage, abandoned calls, and resolution rates.
• Pharmacy help desk performance standards.
• Requirements for reporting on various aspects of the contract, including OHI development, cost avoidance, mail order volumes, and claims processing.

The SOW covers services across the 50 United States, its territories, and overseas locations where TRICARE beneficiaries are served. Specific periods of performance are detailed within the contract, including transition-in and transition-out phases.

• The contractor must adhere to strict data security and privacy requirements, including HIPAA.
• The contractor must manage a Quality Management Plan and provide comprehensive training for its personnel.
• The contractor must establish and maintain various system interfaces and provide detailed documentation.
• The contractor must support contract transition-in and transition-out activities to ensure seamless service delivery.

Form / Attachment / Pricing Sheet

This document appears to be a feedback or comment log related to a solicitation. It is designed for vendors to provide comments, questions, or discussions pertaining to specific sections of a solicitation (Section C or Section H) or general comments if no specific reference applies.

• Section C Reference Number: Field to link comments to a specific part of the solicitation.
• Section H Reference Number: Field to link comments to a specific part of the solicitation.
• Comment, Question, or Discussion related information: The main area for vendors to input their feedback.
• Note 1: Instructs vendors to reference Section C or H for specific comments.
• Note 2: Instructs vendors to use "general" for comments not tied to a specific section.

This document serves as a structured mechanism for bidders to submit feedback, ask clarifying questions, or engage in discussions regarding the solicitation documents. It helps ensure that all vendor feedback is organized and can be properly addressed by the government, potentially leading to clearer requirements and a more competitive bidding process.

Special Contract Requirements

This document outlines "Special Contract Requirements" for a government contract, focusing on:

• Requires contractors to avoid, mitigate, or neutralize any OCI or the appearance thereof.

• Mandates prompt notification to the Contracting Officer (CO) upon knowledge of an actual or potential OCI.

• Requires disclosure of affiliated pharmacies in the retail network and ensures their reimbursement rates do not exceed those of non-affiliated pharmacies.

• Stipulates that contractors must protect proprietary information from unauthorized use or disclosure.

• Details various cost control incentives, including:

  • Retail Network Cost Control Incentive (based on Guaranteed Average Price Adjustment Percentage and Guaranteed Average Dispensing Fee).
  • Retail Network Specialty Cost Control Incentive.
  • Market Priced Pharmaceutical Program (MPPP) Incentive (based on cost savings compared to government pricing).

• Explains the calculation methods, source data, and potential positive or negative incentive amounts.

• Outlines specific requirements and exclusions for eligibility for these incentives.

• Establishes several performance guarantees with specific standards, definitions, application amounts (financial penalties for non-compliance), and measurement methods.

• Guarantees cover areas such as:

  • Mail Order Pharmacy Prescription Processing
  • System Availability
  • Clinical Review Processing
  • Telephone Service
  • Correspondence Processing
  • Formulary Search Tool Corrections
  • TEDS Edit Accuracy
  • Benefit Design Accuracy

• Includes detailed metrics for claims processing, retail network access, beneficiary support, pharmacy help desk, clinical reviews, mail order pharmacy, and formulary search tools.

• Describes the Government's process for conducting quarterly and annual retrospective reviews of TRICARE pharmacy claims data.

• Focuses on identifying payment, occurrence, process, and documentation errors.

• Outlines sampling methodologies and required contractor documentation for these reviews.

• Details the rebuttal process for initial findings.

• Specifies target error rates for claims payment and occurrence.

• Includes requirements for minimum levels of enhanced safeguarding for unclassified information.

• Addresses pilots, demonstrations, and Integrated Product Teams (IPTs).

• Outlines award fee administration.