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. 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 template or form for submitting comments, questions, or discussions related to a solicitation. It guides users on how to reference specific sections of the draft document (Section C or H) or to provide general comments.

• Columns for 'Section C Reference Number', 'Section H Reference Number', and 'Comment, Question, or Discussion related information'.
• Notes instructing users to list the relevant Section C or H reference for their comment, or to use 'general' for broad feedback.

This document is likely provided to potential bidders to facilitate their review of a solicitation and to submit feedback or seek clarification in an organized manner. It helps bidders understand the expected format for providing input during a comment period or Q&A phase.