TRICARE Pharmacy Program RFI (Draft Section C & H)

Other / Unclassified

This document, "Draft Section H.pdf," contains "Special Contract Requirements" for a government contract. It details various sections related to contract clauses, organizational conflicts of interest (OCI), cost control incentives, performance guarantees, and performance metrics.

This document outlines critical contractual terms and conditions that potential bidders must understand. Key areas include:

• Organizational Conflicts of Interest (OCI): Bidders need to be aware of potential conflicts and their responsibilities to avoid, mitigate, or neutralize them. This includes disclosing affiliations with retail network pharmacies and potential conflicts arising from other business relationships.
• Cost Control Incentives: The document details how contractors can earn incentives based on cost savings related to drug pricing (WAC, AWP) and dispensing fees. It outlines the calculation methods for positive and negative incentives, including specific examples.
• Performance Guarantees: A significant portion of the document defines specific performance standards and the financial penalties (forfeitures) for failing to meet them. These 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
• Performance Metrics: Various performance metrics are listed, including system availability, reimbursement claims processing, retail network access, beneficiary support, pharmacy help desk, clinical reviews, mail order pharmacy, and formulary search tool accuracy.
• Claims Compliance and Accuracy Reviews: This section details the government's process for conducting retrospective reviews of pharmacy claims data to ensure compliance with payment integrity regulations, including definitions of error types and sampling methodologies.

Bidders should carefully review these requirements to assess their ability to meet the contract's performance expectations and understand the potential financial implications of non-compliance.

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. The primary objective is to provide comprehensive pharmacy services to approximately 9.5 million active duty and retired Uniformed Service members, their families, and other eligible beneficiaries, ensuring a high-quality, cost-effective healthcare benefit.

The contractor will be responsible for:

• Processing claims from various sources including retail network pharmacies, TRICARE Mail Order Pharmacy (TMOP), Military Treatment Facility (MTF) pharmacies, VA pharmacies, Indian Health Services (IHS) pharmacies, and batch files from State Medicaid Agencies.
• Administering a retail pharmacy network across all 50 states, DC, Puerto Rico, US Virgin Islands, Guam, American Samoa, and Northern Mariana Islands.
• Operating the TRICARE Mail Order Pharmacy (TMOP) program.
• Performing claims adjudication, including eligibility verification, cost-sharing application, Other Health Insurance (OHI) identification, Drug Utilization Review (DUR), and application of catastrophic cap and deductible updates.
• Managing clinical reviews, including prior authorization (PA) and medical necessity (MN) criteria.
• Providing beneficiary and pharmacy support services.
• Ensuring system security and reliability.
• Supporting various interfaces with government systems such as DEERS, PDW, OMDS, and Federal EHR.
• Managing specialty agents, vaccines, and compound prescriptions.
• Supporting MTF pharmacy claims processing.
• Providing customer service and education to beneficiaries and providers.

The SOW details numerous performance standards, including:

• Claims processing system availability of at least 99.5%.
• Timely processing of reimbursement claims (95% within 10 days, 100% within 14 days).
• Timely shipping of mail order prescriptions (98% within 4 business days for non-intervention required, 100% within 10 calendar days).
• Specific call center performance metrics for both beneficiary and pharmacy help desks.
• Reporting requirements for various aspects of the contract.

The SOW covers services across the 50 United States, District of Columbia, Puerto Rico, U.S. Virgin Islands, Northern Mariana Islands, American Samoa, and Guam. Specific periods of performance are detailed throughout the document, including transition-in and transition-out phases.

• Compliance with TRICARE policy, regulations, and laws.
• Adherence to the DoD Uniform Formulary.
• Management of Other Health Insurance (OHI).
• Support for State of Emergency (SOE) declarations.
• Maintenance of a secure and reliable IT infrastructure.
• Compliance with HIPAA and federal information requirements.
• Development and maintenance of a Quality Management Plan and Continuity of Operations Plan (COOP).
• Transition-in and transition-out activities as per specified plans and schedules.

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.