Congressional Research Service Issues Insight White Paper on TRICARE's 5th Generation Pharmacy Contract
Here are excerpts:
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The
Title 10, Section 1074g, of the
On
This Insight provides an overview of TPharm5, proposed retail pharmacy network changes, and DHA contractor performance monitoring.
What is TPharm5?
On
In Section C of the Request for Proposals (RFP), DHA requires the TPharm5 contractor to perform tasks organized under a variety of categories, many of which have existed in previous iterations of the TRICARE pharmacy contract (e.g., TPharm4), including
* establishment and maintenance of a retail pharmacy network and a home delivery program;
* claims processing;
* clinical reviews and management of a prescription monitoring program; and
* beneficiary and pharmacy education, outreach, and customer service.
Figure 1 depicts the TPharm5 acquisition timeline, from 2019 through 2029, if DHA exercises all option periods.
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Figure 1. DHA TPharm5 Acquisition Timeline
Source: CRS graphic based on analysis of
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What changes will occur to the TRICARE retail pharmacy network in
ESI subcontracts with retail chain pharmacies (e.g., CVS or Walgreens) and independent pharmacies to maintain a pharmacy network that meets DHA-established access standards. According to DHA documents provided to CRS, a 2019 independent analysis of the TPharm4 retail pharmacy network identified opportunities for "better quality" and "lower cost," which subsequently informed changes to the network requirements described in TPharm5. Under the Federal Acquisition Regulation (e.g., Part 3.1044), specific TPharm5 contractor bid or proposal information remain proprietary and are not publicly available. However, the TPharm4 RFP and DHA have described some retail pharmacy network requirements that have changed for TPharm5 (see Table 1).
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Table 1. Selected TRICARE Retail Pharmacy Network Requirements, TPharm4 vs. TPharm5
Source: CRS analysis of the requirements described in the TPharm4 and TPharm5 RFPs' Statement of Work; and email communication with DHA officials,
Note:
a. The specific percentage of beneficiaries used in the TPharm4 network access standard is not publicly available.
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As part of the transition from TPharm4 to TPharm5, DHA approved ESI's request to downsize the retail pharmacy network in preparation for the start of the new contract. TRICARE officials announced that starting on
How will DHA monitor TPharm5 contract performance?
The TPharm5 RFP stated that DHA will "utilize a [Quality Assurance Surveillance Plan (QASP)]" to facilitate the monitoring of contract performance. A QASP typically describes what, how, and who will be monitoring contract performance, and how monitoring efforts and results are to be documented. DHA requires ESI to submit reports on various process and outcome metrics specified in a contract data requirements list. Examples of these reports include:
* Retail Network Pharmacy Access Report,
* Prescription Monitoring Program Report,
* Pharmacy Transactions Processing Report, and
* Call Center Top Issues Report.
DHA may also require additional reporting requirements or direct audits and inspections to assist with contract performance monitoring on a periodic or ad hoc basis.
Considerations for
* What education and outreach efforts to beneficiaries and pharmacies will DHA or ESI pursue during the transition to TPharm5?
* What commercial best practices will ESI utilize to deliver an effective and efficient pharmacy benefit?
* How will DHA or ESI ensure beneficiaries in rural or remote areas have adequate and/or equitable access to a network retail pharmacy?
* How will DHA document, consider, and incorporate lessons-learned from TPharm5 into the acquisition strategy for the next TRICARE pharmacy contract?
* To what extent might the reduction in retail network pharmacies result in greater use of the mail-order pharmacy services?
* How might DHA evaluate the impact of the reduction in retail network pharmacies on beneficiary satisfaction?
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The white paper is posted at: https://crsreports.congress.gov/product/pdf/IN/IN12053
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