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.

Other / Unclassified

This document, "Section H Special Contract Requirements," details various contractual obligations, requirements, and performance standards for a contractor. It covers:

• Organizational Conflicts of Interest (OCI): Outlines requirements for identifying, avoiding, mitigating, or neutralizing potential conflicts of interest, including disclosure of affiliated pharmacies and third-party information.
• Cost Control Incentives: Describes two main incentives (Retail Network Cost Control and Specialty Cost Control) and a Market Priced Pharmaceutical Program (MPPP) Incentive. These are designed to reward the contractor for cost savings achieved through price adjustments and efficient dispensing, with detailed calculation methods and examples provided. It also details penalties for exceeding expected costs.
• Performance Guarantees: Establishes specific, measurable performance standards across various areas, including:
  • Mail Order Pharmacy Prescription Processing
  • System Availability
  • Clinical Review Processing
  • Telephone Service
  • Correspondence Processing
  • Formulary Search Tool Corrections
  • TEDS Edit Accuracy
  • Benefit Design Accuracy
  • Beneficiary and Provider Communication and Outreach Significant financial penalties ($1,000,000 or $500,000 per month) are stipulated for failing to meet these standards, with specific measurement criteria and definitions.
• Performance Metrics: Lists various performance standards related to system availability, reimbursement claims processing, retail network access, beneficiary support, pharmacy help desk, clinical reviews, mail order pharmacy, and formulary search tools.
• Claims Compliance and Accuracy Reviews: Details the Government's process for conducting quarterly and annual reviews of TRICARE pharmacy claims data to ensure compliance with payment integrity regulations. This includes sampling methodologies, documentation requirements, and error determination processes (payment, occurrence, and documentation errors).
• Award Fee: Mentions that an award fee will be administered semi-annually.
• Pilots, Demonstrations, and Integrated Product Teams (IPTs): Outlines the potential for the government to require contractors to participate in pilots, demonstrations, or IPTs.
• Safeguarding Requirements: Addresses the need for enhanced safeguarding of unclassified information.

This document is critical for bidders as it defines the operational, financial, and performance expectations of the contract. It details how the contractor's performance will be measured, incentivized, and penalized. Bidders must understand these requirements to accurately assess their ability to meet the contract's demands, including potential cost savings initiatives, stringent performance standards, and significant financial penalties for non-compliance. The detailed performance guarantees and metrics are particularly important for understanding the operational risks and responsibilities involved.

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.