Pharmacy Benefit Manager

The Department of Veterans Affairs (VA) Veterans Health Administration (VHA) Office of Community Care (OCC) Veteran Family Member Program (VFMP) herein collectively referred to as VFMP processes pharmacy transactions for a variety of health benefit programs administered by the VA. The programs include Civilian Heath and Medical Program of the Department of Veterans Affairs (CHAMPVA) 38 CFR, Section 17.270 to 17.278 to include the Caregiver Program, Spina Bifida Healthcare (SB) and Children of Women Vietnam Veterans Healthcare (CWVV) programs 38 CFR, Section 17.900 to 17.905, as well as any future programs identified by VA. The VFMP will adjudicate pharmacy transactions via Health Insurance Portability and Accountability Act (HIPAA) compliant Electronic Data Interchange (EDI).

The VFMP intends to utilize the expertise of a Pharmacy Benefit Manager (PBM) with an extensive nationwide network of retail pharmacies throughout the 50 United States, District of Columbia, Puerto Rico, Guam, the United States (U.S) Virgin Islands, the Northern Mariana Islands, the American Samoa, and the Minor Outlying Islands.

The estimated prescription activity based upon fiscal year 2021 data for all programs is 5,289,000 prescriptions for approximately 260,000 active PBM enrollees. Administration Fee, Transaction Fee, and Drug Utilization Fee shall be priced independently and invoiced accordingly. Dispensing Fee not being an Administrative Fee will not be invoiced monthly by the Contractor but billed separately at the contracted rate through the National Counsel of Prescription Drug Programs (NCPDP) claim transaction by way of electronic submission to VFMP and processed through the claim system (currently Claims Processing & Eligibility (CP&E)). (Ref.: Section Beneficiary Cost Share).

The Contractor shall work with the Program Office (PO), Contracting Officer (CO), and Contracting Officer Representative (COR) to accept and submit electronic pharmacy claims from the Contractors network providers at the point of sale. At no time shall the Contractor direct, change, or engage in the formulation of the VHA policy. VHA is solely responsible for the review of Contractor’s recommendations and making all policy/policy formulation decisions.